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MODERN 

Operative  Bone  Surgery 

WITH  SPECIAL  REFERENCE 
TO   THE 

Treatment  of   Fractures 


BY 

CHARLES  GEORGE  GEIGER,  M.D. 


WITH  120   ILLUSTRATIONS 


PHILADELPHIA 
F.  A.  DAVIS  COMPANY,  Publishers 

ENGLISH   DEPOT  : 
STANLEY   PHILLIPS,  LONDON. 

1918 


COPYRIGHT,  191S 

BY 
F.   A.   DAVIS   COMPANY 

Copyright,  Great  Britain.     All  Rights  Reserved 


PRESS    OF 

F.     A.     DAVIS     COMPANY 

PHILADELPHIA.  U.  S.  A. 


DEDICATED 

TO    THE 

MEMORY  OF  THE  HIGHLY  ESTEEMED 
AND  BELOVED 

JOHN    B.   MURPHY 


<3L 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/modernoperativebOOgeig 


PREFACE. 


The  great  demand  for  a  comprehensive,  yet 
abridged,  book  on  "Plastic  Bone  Surgery"  suitable 
for  the  busy  surgeon,  presenting  clearly  the  mod- 
ern methods  and  mechanical  means  for  perfecting 
such  work,  has  been  firmly  impressed  upon  the 
mind  of  the  author  in  the  last  three  years  by  the 
great  number  of  inquiries  from  this  and  foreign 
countries  for  a  book  dealing  with  this  subject.  It 
was  with  a  keen  appreciation  of  this  demand  that 
the   present   volume  was   undertaken. 

Following  these  ideas,  the  author  has  en- 
deavored to  give  the  facts  in  autoplastic  bone 
work  and  the  modern  instruments  used  in  such 
work  as   briefly   as   is   compatible   with   clearness. 

It  has  been  a  difficult  task,  because  there  is 
no  similar  work  on  this  subject  published  up  to 
the  present  time.  All  previous  publications  on 
bone  surgery  are  largely  composed  of  reports  of 
cases. 

The  transplantation  of  bone  is  not  an  entirely 
new  procedure,  and  the  advent  of  asepsis  and  the 
development  of  the  electro-operative  motor  instru- 
ments have  made  possible  its  extensive  applica- 
tion. The  dependable  methods  of  obtaining  asep- 
sis in  bone  surgery  must  withstand  the  closest 
detailed   scrutiny. 

(v) 


vj  PREFACE. 


Bone  being  a  connective  tissue,  lends  or  gives 
itself  favorably  to  transplantation,  and  to  the  re- 
pair of  defects  and  deficiencies  of  the  skeleton. 
It  is  the  only  safe  and  reliable  internal  fixation. 
By  the  use  of  autogenous  material  the  surgeon 
follows  nature's  own  method,  and  is  thereby  able 
to  overcome  mechanical  surgical  defects  which 
hitherto   he    was    unable   to   deal    with    successfully. 

The  application  of  external  fixation-braces,  and 
the  uncertain  extemporizing  methods,  cannot  com- 
pare with  the  autogenous  bone-graft  accurately 
and   directly   implanted. 

The  reader  will  recognize,  after  a  careful  re- 
view of  the  voluminous  literature  of  the  last  few 
years,  the  difficulty  of  justly  estimating  the  value 
of  conflicting  opinions;  therefore,  a  judicial  and 
careful  selection  from  the  vast  material  is  the 
most  important  duty  of  the  writer. 

The  author  is  deeply  indebted  to  the  late  John 
B.  Murphy  for  the  privilege  of  selecting  from 
his  extensive  library  valuable  rontgenograms, 
many  of  which  are  used  in  this  volume,  and  also 
for   his   many   suggestions. 

The  author  is  also  obligated  to  Dr.  Arthur  H. 
Hertzler  for  his  most  valuable  criticisms  and  cor- 
rections. 

C.    G. 


CONTENTS. 


CHAPTER  PAGE 

I.    Histology  of  Chondrin.    Cartilage  1 

II.    Histology  of  Periosteum  and  Bone  5 

III.  General   Consideration   of  the   Functions   of   the 

Periosteum  23 

IV.  Repair  of  Bone 32 

V.    Repair  of  Bone,  in  Detail  36 

VI.    Evolution  that  has  taken  place  in  the  Treatment 

of  Fractures  40 

VII.     Operative  Treatment  of  Fractures:    Factors  to  be 

Accomplished    46 

VIII.    The  Use  of  Foreign  Material  51 

IX.    Technic  of  Transplanting  Bone 58 

X.    Instruments  and  Their  Use 67 

XI.    Required  Efficiency  of  the  Motor 72 

XII.     Description  of  the  Author's  Motor,  Instruments  or 

Cutters,  and  Accessories  76 

XIII.  Orthopedic  and  Fracture  Extension  Device 94 

XIV.  Remarks  on  Technic  104 

XV.    Elements    Essential   in    a    Transplant   For    Con- 
tinued Success  109 

XVI.  The  Use  of  an  Inlay-graft 116 

XVII.  Technic  in  the  Application  of  an  Intramedullary 

Dowel  120 

XVIII.  The  Use  of  the  Bone-peg  in  Cortical  Bone 124 

XIX.  Things  Essential  in  Treating  Fractures  126 

XX.  Time  to  Operate  on  Fresh  Fractures  131 

XXI.  Special  Fractures  ;  Inferior  Maxillary 141 

XXII.  Fracture  of  the  Clavicle 143 

XXIII.  Fractures  of  the  Humerus  146 

XXIV.  Fractures  of  the  Forearm  168 

XXV.  Fractures  of  the  Femur 178 

(vii) 


VI 11 


CONTEXTS. 


CHAPTER 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 

XXX. 

XXXI. 

XXXII. 

XXXIII. 

XXXIV. 

XXXV. 


XXXVI. 
XXXVII. 

XXXVIII. 

XXXIX. 


PAGE 

Fractures  of  the  Patella  196 

Fractures  of  the  Tibia  and  Fibula  203 

Fractures  of  the  Os  Calcis  207 

Fractures  of  the  Spine 211 

Postoperative  Fractures  of  the  Tibia  213 

Delayed  Union  and  Ununited  Fractures  215 

Application  of  the  Intramedullary  Transplant  in 

Ununited  Fractures 230 

Club-foot  232 

Spina  Bifida  236 

Autogenous  Bone-graft  Used  in  Replacing  Shaft 
and  Articulating  Surface  of  Long  Bones  Re- 
moved on  Account  of  Mutilation  and  Disease  238 

Remodeling  or  Repairing  the  Xose  245 

Tuberculosis  of  the  Vertebr.e  248 

Bone-inlay    Grafts    in    the    Treatment    of    Pott's 

Disease 256 

Hibbs'  Operation  for  the  Cure  of  Pott's  Disease  . .     274 


LIST    OF    ILLUSTRATIONS. 


FIG.  PAGE 

1.  Skiagraph  illustrating  the  axillary  artery  and  its  branches   .  .       9 

2.  Skiagraph    of    elbow    showing    fracture    of   the   internal    and 

external  condyles  of  humerus   11 

3.  Illustrating  circulation  of   forearm,   wrist,   and  part  of  hand 

(/.  B.  Murphy)    12 

4.  Illustrating  circulation  of  pelvis  and  hip.     (/.  B,  Murphy)    . .  13 

5.  Posterior  view  of  the  lower  portion  of  leg  and  foot  14 

6.  Skiagraph  of  the  knee-joint  showing  the  popliteal  artery  with 

its   numerous  branches    16 

7.  Skiagraph  of  the  arm  showing  a  vicious  fracture  of  humerus.  37 

8.  Fractured   neck  of   femur    41 

9.  Fracture  of  lower  end  of  humerus  near  elbow-joint  42 

10.  Oblique   fracture  of  the   femur  near  junction   of  the  middle 

with  upper  third   43 

11.  Fracture     of     the     humerus     near     juncture     of     middle     of 

lower  third    44 

12.  Outlining    bone-inlay    used    to    hold    fragments    together    in 

fracture  of  patella   47 

13.  Illustrates  the  author's  method  of   removing  the  rectangular 

dowel   from  the  distal   fragment  in   fracture   of  the  ole- 
cranon process   47 

14.  Pott's   fracture  with  internal  malleolus  broken  off    49 

15.  Fracture  of  upper  third  of  humerus  just  above  insertion  of 

deltoid  muscle 52 

16.  Same  as  Fig.   15.     Lane'  plate  has  been   removed,   and  intra- 

medullary dowel  applied  53 

17.  Same  as  Fig.  14.     Side  view  of  Pott's  fracture,  showing  three 

nails  in  position   55 

18.  A,  fracture  of  both  bones  of  forearm.     B,  six  months  after 

intramedullary  dowel  was  applied    56 

19.  Fracture  of  lower  portion  of  humerus  extending  into  joint.  .  .  61 

20.  Showing  reduction  gear  in  author's  motor  68 

21.  Illustrating'  position  in  which  the  late  John  B.  Murphy  held 

author's  motor  while  doing  bone-work   69 

22.  Skiagraph  showing  an  oblique  fracture  of  the  tibia  and  fibula.  70 

23.  Right  angle  arm  used  in  deep  wound    72 

24.  Showing  T-wrench  in  position  in  motor  chuck   73 

25.  Illustrating    extra    guide    handle    in    position    on    sterilizable 

motor    74 

26.  The  author's  sterilizable  shell   74 

27.  Electric  hot  air  sterilizer  with  thermostatic  control 76 

28.  Displaying  author's  unsterilized  motor  being  placed  in  steril- 

ized  shell    77 

29.  Shows    the    author's    motor    being    used    without    sterilizable 

shell   78 

30.  One  of  the  positions  in  which  the  motor  may  be  held 78 

(ix) 


x  LIST    OF   ILLUSTRATIONS. 

FIG.  PAGE 

31.  Sterilized  chuck  being  attached  to  motor   79 

32.  A  complete  set  of  the  author's  bone  instruments,  etc 81 

33.  The  author's  latest  idea  of  motor  bone  saw   82 

34.  Extra  guide  handle  for  single  or  parallel  saws    83 

35.  Two-inch  single  saw  with  saw-guard  for  regulating  depth  of 

saw    84 

36.  Saw-guards,  eight  in  number,  for  regulating  depth  of  saws  . .  84 

37.  Author's  sharp-nosed  burr  85 

38.  Author's   caliper   knives    85 

38A.     Author's  periosteotome    86 

39.  Author's  tube-saw  or  dowel-shaper   86 

40.  Tube  saw  or  dowel  shaper  with  lathe  attachment  in  position  .  87 

41.  Author's  motor  trephine   87 

42.  Author's  motor  protected  burr  or  cranial  cutter   88 

43.  Author's  protected  burr  or  skull  cutter  89 

44.  Author's  bone-graft  retaining  forceps  with  projecting  jaws  . .  89 

45.  The  author's  twin  saws  with  extra  guide  handle 90 

46.  Author's  right-angle  arm  in,  position  on  sterilized  motor   ...  90 

47.  The  author's  bone-elevating  forceps   91 

48.  Author's  bone  skids  or  elevating  spoons  92 

49.  Author's   bone-clamp    92 

50.  Author's  extension  device  attached  to  operating  table  94 

51.  Author's  extension  device  knocked  down,  ready  to  be  placed 

in  carrying  case  95 

52.  Author's  extension  device  with  hand  in  position  on  handpiece 

and  arm-rest  96 

53.  Author's  orthopedic  and  fracture  extension  device   96 

54.  Side-view    of    author's    orthopedic    and    fracture    extension 

device    97 

55.  Displaying  footpiece  of  author's  extension  device 98 

56.  Demonstrating1  the  application  of  spica  bandage  to  hip 99 

57.  Author's   extension    device,    with    head-    and    shoulder-    rests 

in  position    100 

57a.     Exhibits  extension  arms  of  the  Gciger-Murphy  fracture  and 

extension  table,  in  position  with  saddle  102 

57b.     Displaying  Geiger-Murpliy  fracture  and  extension  table,  with 

head-  and  shoulder-  rest  and  extension  arms  in  position.  .   103 

58.  A,  Geiger  motor  plaster-of-Paris  cutter;  B,  plaster-of-Paris 

cutter  in  operation    Ill 

59.  Illustrates  sliding-graft  being  removed  from  fragment   114 

■60.     Illustrates  the  sliding-graft  in  position   114 

61.  Cross-section  of  the  inlay  transplant  of  a  long  bone  116 

62.  Cross-section  of  long  bone  with  rectangular  inlay  graft  held 

in  position  by  bone-pegs   117 

63.  Cross-section  of  clavicle,  illustrating  the  author's  method  of 

making  use  of   an  inlay  graft  removed   from   the   frag- 
ments  of  clavicle    143 

64.  Fracture  of  neck  of  humerus  with  considerable  deformity  . .  .    147 

65.  Fracture  of  the  neck  of  humerus,  showing  8-penny  nail  driven 

through  distal  fragment  into  head  148 

66.  Showing  Langenbeck's  incision 149 

67.  Fracture  of  the  surgical  neck  of  the  humerus   151 

68.  Showing  the  use  of  the  round  bone-peg 151 

69.  Fracture  of  anatomical  head  of  humerus   153 


LIST    OF    ILLUSTRATIONS.  xi 

FIG.  PAGE 

70.  Same  as  Fig.  69,  after  application  of  rectangular  intramedul- 

lary dowel   154 

71.  Illustrates  the  use  of  the  rectangular  dowel .   155 

72.  Fracture  of  head  of  humerus,  with  two  8-penny  fence  nails 

driven  through  distal  fragment   (/.  B.  Murphy)    157 

73.  Illustrates  the  author's  method  of  removing  graft   158 

74.  A,  fracture  of  humerus  near  middle  of  lower  third :  B,  three 

months  after  application  of  intramedullary  dowel 160 

75.  Illustrating  fracture  of  humerus  after   fragments  have  been 

placed  in  position  and  intramedullary  dowel  applied 161 

76.  A,  fracture  of  humerus  near  middle  of  middle  third ;  B,  two 

weeks   after   rectangular  intramedullary   dowel   had  been 
applied    .•••••. -^ 

77.  Transverse    fracture    of    the    humerus    near   junction    of   the 

middle  with  lower  third 163 

78.  Fracture   of   lower   end   of   humerus   with   deformity    (/.   B. 

Murphy)    164 

78a.     Same  as  Fig.  78.     Illustrating  fragments  held  together  with 

an  ordinary  8-penny  finishing  nail 165 

79.  T-f racture  with  two  10-penny  finishing  nails   167 

80.  Fracture  of  the  olecranon  (/.  B.  Murphy)    168 

81.  Showing    10-penny   finishing   nail    driven    through    olecranon 

process  into  shaft  of  ulna  (/.  B.  Murphy) 169 

82.  Shows  the  sliding  inlay  graft  removed  from  the  distal  frag- 

ments of  fractured  end  of  olecranon  process .    170 

83.  A,   fracture  of  radius ;   B,  showing  intramedullary   dowel   in 

position    • 172 

84.  Fracture  of  ulna  near  the  junction  of  the  middle   with  the 

lower  third ;•.•••-. ^ 

85.  Showing  rectangular  dowel-graft  driven  in  position  in  frac- 

ture of  neck  of  femur   _ 178 

86.  Diagram  illustrating  the  rectangular  dowel  used  in  fractures 

of  the  surgical  neck  of  the  femur   179 

87.  Fracture  of  neck  of  femur  181 

88.  Fracture  of  the  hip  183 

89.  Same    as    Fig.    88,    displaying    two    12-penny    spikes    driven 

through  the  greater  trochanter  185 

90.  Antero-posterior  view  of  fracture  of  the  femur  191 

91.  Fracture  of  the  patella  •  •  ■  ■   197 

92.  Same  as  Fig.  91.    Shows  fractured  fragments  of  patella  wired 

together  by  bronze  wire    198 

93.  Spool-shaped  type  of  inlay  graft  usually  used  in   fracture  of 

patella 199 

94.  Shows  inlay  graft  with  enlarged  or  dilated  ends  used  in  frac- 

ture of  the  patella  • 201 

95.  A,  fracture1  of  lower  portion  of  tibia  and  fibula,  with  bad  de- 

formity :  B,  same  as  A  205 

96.  Transverse  fracture  of  the  os  calcis 209 

97.  A,  fracture  of  tibia  and  fibula,  with  nonunion  after  wiring  of 

the  tibia.    B,  same  as  A.    Two  years  after  operation 216 

98.  Skiagraph  of  ununited  fractures  of  tibia  and  fibula  in  child  . .   218 

99.  A,   same   as   Fig.   98.     Illustrating   intramedullary   dowel   ten 

weeks  after  application.  Antero-posterior  view.  B,  same 
as  Figs  98  and  99 A  Eight  months  after  the  application 
of  intramedullary  dowel  in  the  tibia  219 


xii  LIST    OF    ILLUSTRATION'S. 

FIG.  PAGE 

100.  Same  as  Figs.  98  and  99.  A  and  B.     One  year  after  placing 

of  intramedullary  dowel  in  tibia   221 

101.  Pott's  fracture  six  months  after  accident   223 

102.  Upper  portion   of   leg  showing  almost   entire   destruction   of 

upper  half  of  tibia 224 

103.  Same  as  Fig.  102.     Shows  12-inch  transplant  in  position  three 

months   after   application    225 

104.  A,  showing  absence  of  a  part  of  lower  portion  of  tibia:  B, 

same  as  A,  with  intramedullary  dowel  in  position 227 

105.  Illustrating  removal  of  a  wedge-shaped  piece  taken  from  the 

outer  and  convex  surface  of  the  foot  233 

106.  Appearance  of  the  foot  after  a  wedge-shaped  piece  had  been 

removed  from  the  outer  surface  in  an  exaggerated  case  of 
talipes   equinovarus 233 

107.  Upper  half  of  humerus  enlarged   239 

108.  Case  of  osteitis  fibrosa  cystica  of  the  lower  articulating  sur- 

face of  the  radius    240 

109.  Osteitis  fibrosa  cystica  involving  upper  extremity  of  femur  for 

about  one-third  distance   241 

110.  Same  as  Fig.  109.    After  removal  of  diseased  bone,  including 

articulating   surface    242 

111.  Same  as  Fig.  109.     Nine  months  after  operation   243 

112.  Showing  the  "Don"  operation  257 

113.  Albee's  method  of  splitting  the  spine  of  the  vertebra  perpen- 

dicularly     259 

114.  Position  from  which  to  remove  the  graft  to  be  used  in  a  case 

of  Pott's  disease  where  there  is  marked  kyphosis   263 

115.  Modified  Albee's  method  of  placing  bone-graft  in  spine   for 

the  cure  of  Pott's  disease  265 

116.  Hibbs'  operation  for  the  cure  of  Pott's  disease   274 


INTRODUCTION. 


In  the  Library  at  Leipsic  is  the  celebrated 
hieratic  medical  papyrus  which  was  discovered  by 
George  Moritz  Ebers,  a  German  Egyptologist  and  f 
novelist,  born  in  Berlin  in  1837.  While  travel- 
ling in  Egypt  in  1872  he  discovered  the  hieratic 
medical  papyrus  which  is  now  known  as  the 
"Papyrus  Ebers,"  which  dates  back  one  thousand 
and  fifty-five  years  B.C.  It  is  one  of  the  best 
preserved  Egyptian  papyri  in  existence,  and  forms 
the  chief  source  of  information  in  regard  to  the 
medical    knowledge    of    the    ancient    Egyptians. 

It  is  evidenced  by  these  ancient  records  that 
rhinoplastic  operations  were  performed  then  by 
the  flap  method.  The  ancient  Hindoo  specialists 
made  new  noses  from  the  frontal  tissues  long  be- 
fore the  time  of  the  noted  Italian  surgeon,  Taliac- 
otius.  The  Hindoos  replaced  the  cartilage  por- 
tion, cut  oft"  as  a  punishment  for  adultery  or 
other  reasons,  by  a  cutaneous  flap,  turned  down 
from  the  forehead.  Taliacotius,  in  the  sixteenth 
century,  made  noses  and  lips  from  the  tissues  of 
the.  arm ;  he  thus  improved  the  features  resulting 
from  disfigurement  in  war,  or  by  disease,  many 
years   before   the    days    of    Dieftenbach. 

Plastic  or  reconstructive  surgery  has  made 
wonderful  strides  since  its  revival,  in  the  first 
half  of  the  nineteenth  century,  by  Dieftenbach  and 

(xiii) 


xiv  INTRODUCTION. 

his    contemporaries    in    Europe,    and    Muetter    and 
his   followers   in   America. 

The  development  and  history  of  this  branch  of 
our  art  is  as  attractive  as  that  of  aviation.  Both 
would  easily  evoke  in  one's  mind  a  pleasure  akin 
to  that  responding  to  the  touch  of  a  novelist's 
pen. 

Wolff,  the  noted  Scotch  surgeon,  was  able  to 
convince  a  few  of  his  profession  that  a  free  flap 
or  graft  of  skin  taken  from  a  distant  portion  of 
the  body  could  be  successfully  transplanted  to  cor- 
rect   eversion    of    the    eyelid. 

His  method  of  dissecting  up  the  ectropion,  re- 
placing the  eyelid,  and  filling  the  raw  gap  with 
a  piece  of  detached  skin,  was  often  tried,  but  this 
operation  failed  too  frequently  to  become  a  stand- 
ard   procedure. 

Then  came  another  celebrated  Scotchman,  Lord 
Lister,  who  died  but  a  few  years  ago,  and  who 
did  so  much  to  improve  surgical  operative  tech- 
nic  by  developing  and  demonstrating  the  importance 
of  asepsis  in  surgical  work. 

Krause,  of  Germany,  then  came  forward,  who 
developed  the  usefulness  of  the  free  flap  or  graft 
of  Wolff,  by  using  it  in  general  surgery,  and  safe- 
guarding it  with  an  antiseptic  technic. 

Experimental  research  and  clinical  observation 
have  proved  that  all  tissues  are  governed  by 
physiological  laws,  the  same  as  those  regulating* 
the  cell-life  and  cell-death  of  the  skin.  Thought- 
ful men  with  broadened  minds  during  the  past 
half   century   have   demonstrated   fully   that   all   tis- 


INTRODUCTION.  xv 

sues — teeth,  tendons,  blood-vessels,  nerves,  fascias, 
cartilage,  and  bone — may  be  removed  from  one 
portion  of  the  body  and  transplanted  to  another, 
and  live  and  grow  and  become  a  part  of  the  tis- 
sue in  which  it  is  transplanted.  The  patient's  own 
tissue  is  far  superior  to  that  of  any  other  in- 
dividual for  these  operations.  The  tissue  from  a 
young  person  lives  and  grafts  more  readily  than 
from   the   aged. 

To  Dr.  Oilier,  of  France,  should  be  given  great 
credit  in  the  field  of  orthopedic  surgery,  for  it 
was  his  work,  and  the  stimulus  which  he  gave 
to  the  profession,  that  established  the  possibility 
of  using  bone  in  plastic  operations.  It  is  almost 
fifty  years  since  Oilier  first  gave  special  attention 
to  this  branch   of   surgery. 

The  wonderful  development  now  seen  in  osteo- 
plastic work  exceeds  the  march  of  progress  found 
in  other  branches  of  surgery.  The  methods  of 
Oilier  have  been  modified  by  the  result  of  in- 
creasing knowledge  and  the  invention  of  modern 
electro-operative  instruments  suitable  for  such 
work. 

Honorable  mention,  since  Ollier's  time,  is  due 
Tomita,  Grohe,  Morpurto,  Macewen,  Axhausen, 
Murphy,  Janeway,  Hibbs,  Albee,  and  others,  who 
have  done  much  clinical  and  experimental  work  in 
osteoplastic  surgery. 

In  this  volume,  only  the  autogenous  bone 
transplant  will  be  considered,  for  it  is  the  safe 
and   sound  procedure. 

Charles    Geiger. 


CHAPTER   I. 
Histology  of  Chondrin.     Cartilage. 

Ix  studying  the  histogenesis  of  cartilage  and 
bone,  the  fact  is  revealed  to  us  that  there  are 
still  a  number  of  disputed  points  in  regard  to  the 
formation   and   structure  of   these   tissues. 

I  shall  deal  as  lightly  as  possible  with  the 
minute  cellular  changes  that  take  place  in  the  re- 
generation of  cartilage  and  bone;  however,  there 
are  certain  fundamental  points  that  must  be 
described. 

Both  of  these  tissues,  cartilage  and  bone,  when 
fully  developed,  are  very  easily  distinguished  from 
one  another,  and  there  is  nothing  to  suggest  that 
they  have  a  close  developmental  relationship.  Car- 
tilage is  flexible,  smooth,  cuts  easily,  and  has  a 
glistening  surface  and  a  homogeneous  structure; 
bone  is  firm,  very  difficult  to  cut,  and  has  a  tough, 
irregular  surface,  with  a  complex  architecture. 
Microscopically,  cartilage  cells  are  situated  in  a 
uniform  ground  substance,  of  a  singular  type, 
varying  only  in  size  and  shape;  large  and  round 
in  the  center,  small  and  flat  towards  the  peri- 
phery, where  they  gradually  pass  into  a  surround- 
ing membrane,  called  the  perichondrium. 

Microscopically,  bone-cells  are  of  various  types; 
in  the  center  is  the  complex  marrow,  beyond 
which  is  the  cortex,  made  up  of  characteristic 
bone-cells,    lying    in    a    uniform    ground    substance. 

(1) 


2  MODERN    OPERATIVE   BONE   SURGERY. 

The  entire  structure  is  surrounded  by  a  thin  mem- 
brane,  called  the  periosteum. 

The  embryological  origin  of  cartilaginous  bone, 
its  close  relation  to  cartilage,  is  apparent,  as  it 
arises  from  a  blastemal-syncytium  of  white  fibrous 
tissue,  and  it  passes  through  an  intermediate  car- 
tilaginous  stage. 

The  chief  problems  to  be  considered  are,  the 
relative  importance  of  the  original  cartilage,  and 
the  perichondrium   in   forming  the   new   cartilage. 

The  histogenesis  of  bone  reveals  the  fact  that 
there  are  a  number  of  disputed  points  regarding 
the  method  or  methods  of  its  formation;  in  this, 
the  chief  problems  to  be  considered  are  the  rela- 
tive importance  of  the  original  bone  and  the 
periosteum  in  forming  the  new  bone.  In  the 
transformation  of  cartilage  into  bone  the  peri- 
chondrium takes  a  very  active  part  in  the  endo- 
chondral ossification.  Following  the  penetration 
of  the  perichondria!  buds  into  the  cartilage, 
changes  take  place  by  which  the  marrow  cavity 
and  cancellous  bone  are  formed.  The  exact  man- 
ner in  which  the  cartilage  is  formed  into  bone 
has  not  been  fully  ascertained.  Some  investi- 
gators think  that  there  is  a  direct  change  of  car- 
tilage-cells into  bone-cells;  others  believe  that  the 
new  bone  is  formed  outside  the  old  cartilage, 
which  only  acts  as  a  direct  framework  for  the 
new  bone.  However,  with  the  change  within  the 
center  of  the  cartilage  co-incidentally  there  is  a 
direct  deposition  of  bone  beneath  this  perichon- 
drium. 

After    the    bony    stage    has    been    reached,    the 


HISTOLOGY    OF    CHOXDRIX.     CARTILAGE.  3 

perichondrium  becomes  the  periosteum,  and  the 
chondroblasts  become  the  osteoblasts.  Thus,  it  is 
believed  that  there  is  a  very  close  relation  be- 
tween the  perichondrium  and  the  periosteum, 
between  the  chondroblasts  and  the  osteoblasts,  be- 
tween the  cartilage  and  the  bone;  and  it  would 
only  be  natural  to  expect  a  certain  parallelism 
in  the  methods  of  regeneration  of  two  tissues  so 
closely  related  in  their  development. 

The  perichondrium  is  the  thin  membrane  which 
can  be  separated  from  the  underlying  cartilage, 
providing  the  exact  line  of  cleavage  is  found  at 
or  near  the  chondro-osseous  junction.  It  becomes 
thicker  and  more  adherent,  and  so  continues  with 
the  periosteum.  Without  the  microscope  it  is  im- 
possible to  make  out  any  separation  between  the 
perichondrium    and   the   true    cartilage. 

The  outer  layer  of  the  perichondrium  consists 
of  a  loosely  arranged  fibrous  tissue,  beneath  which 
are  longitudinally  placed  plate-like  nuclei.  In  the 
next  layer  the  nuclei  are  large,  oval  in  shape,  and, 
when  stained,  lighter  in  color,  and  are  not  so 
close  together.  These  latter  nuclei  shade  off 
gradually  into  a  group  which  are  slightly  larger, 
and  have  a  more  vascular  appearance;  many  of 
the  latter  are  in  pairs,  as  though  they  were 
divided. 

There  is  a  general  idea  that  cartilage  possesses 
only  slight  power  of  regeneration,  and  it  is  even 
held  by  some  that  this  power  is  entirely  lacking. 
The  greater  number  of  investigators  admit  that 
cartilage    has    the    property    of    regeneration,    but 


4  MODERN    OPERATIVE   BONE   SURGERY. 

there  is  no  uniformity  of  opinion  as  to  the  exact 
manner. 

The  consensus  of  opinion  is  that  the  regenera- 
tion takes  place  from  the  perichondrium;  the 
transformation  from  the  fibrous  connective  tissue 
to  the  simple  cartilage  and  the  complex  bone  in- 
volves as  intricate  a  developmental  problem  as  is 
met  with  in  any  of  the  developmental  changes 
within  the  body. 

In  the  study  of  cartilage  and  bone  it  will  be 
noticed  that  certain  cells  possess  the  inherent 
tendency  to  produce  these  specific  types  of  tissue; 
and  although  we  cannot  hope  to  determine  what 
that  stimulating  factor  may  be,  we  should  at  least 
be  able  to  arrive  at  a  uniform  interpretation  of 
the  various  steps  of  the  process. 

Here,  as  in  all  other  regenerative  and  develop- 
mental changes,  some  unknown  factor  or  forces 
initiate  the  transformation  that  takes  place.  This 
influence  is  often  referred  to  as  the  inherent  or- 
ganization of  the  germs,  but  as  yet  no  one  has 
any  definite  conception  as  to  what  that  organiza- 
tion is. 

In  the  early  development  of  the  foetus,  many 
of  the  cells  of  the  somatic  and  splanchnic  meso- 
derm are  transformed  into  what  is  known  as  the 
mesenchyme.  The  mesenchyme  is  the  forerunner 
of  connective  tissue.  These  tissues  are  intimately 
associated  with  the  formation  of  all  the  organs 
of  the  body,  and  also  become  definite  membranes, 
cords,  or  solid  masses,  etc.,  i.e.,  fascia,  tendons, 
ligaments,  cartilage,   and  bone. 


CHAPTER   II. 
Histology  of  Periosteum  and  Bone. 

Bone  may  form  either  from  fibrous  tissue,  in 
which  case  it  is  known  as  intramembranous  bone, 
or  it  may  develop  from  cartilage,  as  in  intermedial 
stage,  and  then  it  is  known  as  intercartilaginous, 
or  endochondral,  bone.  In  either  case,  it  is  de- 
veloped from  mesenchyme,  but  differs  from  other 
mesenchymatous  derivatives  in  that  bone  is  never 
of  primary  formation,  either  developing  in  pre- 
formed fibrous  tissue   or   cartilage. 

In.  the  intramembranous  development,  when  the 
inherent  organic  power  of  the  organism  stimulates 
the  fibrous  tissue  to  become  differentiated  into 
osseous  tissue,  certain  cells,  known  as  osteoblasts, 
deposit  calcium  salts  in  the  fibrous  tissue  matrix, 
forming  a  network  of  bone  spicula.  These  spic- 
ula,  as  development  continues,  increase  in  thick- 
ness, and  extend  farther,  radiating  in  all  direc- 
tions,  into  the   connective   tissue  matrix. 

Later  on,  the  cells  of  the  mesenchyme,  which 
are  directly  adjacent  to  the  reticular  plate  of  bone, 
previously  produced,  are  seen  to  condense,  and 
form  "a  stout  membrane".  This  membrane  be- 
comes what  is  known  as  the  periosteum.  By  the 
time  the  periosteum  becomes  recognizable  as  a 
distinctly  condensed  membrane,  a  layer  of  osteo- 
blasts  arrange   themselves   in   a   more   or   less   defi- 

(5) 


6  MODERN    OPERATIVE   BONE    SURGERY. 

nite  manner  between  the  periosteum  and  develop- 
ing bone. 

Being  limited  externally  by  the  fibrous  tissue 
membrane,  the  osteoblasts  deposit  a  lamella  of 
compact  bone.  The  histological  structure  of  the 
periosseous  layer  is  intimately  associated  with  the 
function  of  the  periosteum;  its  component  cellular 
elements  increase  or  decrease,  numerically,  directly 
with  the  physiological  or  pathological  variation  of 
its   function. 

In  adult  bone,  its  function  is  slightly  different 
from  that  of  young  bone,  and  extremely  variant 
from   that   of   irritated   bone. 

Bone  is  not  a  simple  crude  mass  resulting 
from  the  calcification  of  cartilage  or  fibrous  tis- 
sue. It  is  a  highly  developed  form  of  connective 
tissue.  It  is  in  reality  a  white  fibrous  tissue,  cal- 
cified and  structurally  modified  until  it  becomes 
osseous  tissue.  It  is  distinctly  a  different  struc- 
ture, the  constituent  parts  of  which  are  arranged 
systematically. 

Two  distinct  varieties  of  bone  exist;  compact, 
or  dense  bone,  and  loose,  spongy  or  cancellous 
bone.  Dense  bone  is  compact,  and  is  always 
found  upon  the  exterior  part  of  the  bone-tissue. 
Even  this  apparently  compact  bone  is  porous.  It 
differs  from  spongy  bone  only  in  its  greater  den- 
sity, and  in  the  arrangements  of  its  osseous  sub- 
stances into  lamellae.  It  particularly  forms  the 
shafts  of  the  long  bones,  and  constitutes  the  outer 
portion  of  their  extremities,  and  of  the  short,  flat 
and    irregular    bones.      Excepting    the    dentine    and 


HISTOLOGY  OF  PERIOSTEUM  AND  BONE.      7 

enamel,  it  represents  the  hardest  substance  of  the 
body.  It  is  elastic  and  tough,  and  much  force  is 
required  to  break  it.  All  bones  possess  two 
membranes;  the  covering  or  periosteum,  and  the 
lining  or  endosteum.  The  periosteum  is  a  dense 
tissue,  which  is  firmly  attached  to  the  bone  by 
trabecular  of  fibrous  tissue  (Sharpey's  fibers), 
which  penetrate  the  bone  at  right  angles  to  its 
surface,  and  carry  blood-vessels  into  the  dense 
bone.  They  do  not  directly  enter  the  Haversian 
system,  but  only  circumferential  and  intermediate 
lamellae — parts'  that  are  formed  by  periosteal 
action.  Some  of  these  vessels,  however,  communi- 
cate with  the  Haversian  canal,  and  even  with  the 
endosteum  and  marrow  indirectly,  and  play  a 
most  important  part  in  the  result  of  a  transplant. 
There  are  no  Haversian  canals  in  the  outer  layer, 
but  here  are  found  in  the  large  channels  Volk- 
mann's  canals.  The  interstitial  or  intermediate 
lamellae  occupy  the  spaces  between  the  Haversian 
systems.  They  represent  the  remains  of  peri- 
pheral lamellae.  They  are  usually  short,  and  very 
irregular,  but  possess  lacunae  and  canaliculi,  and 
are  arranged  as  in  the  Haversian  system,  and 
with  which  they  connect. 

The  Haversian  or  concentric  lamellae  are  cir- 
cular layers,  arranged  around  a  center  space  or 
canal,  known  as  "a  Haversian  canal".  There  is 
no  fixed  number  of  these  layers,  there  being  usu- 
ally from  five  to  ten.  The  layers  of  each  system 
are  parallel  to  one  another,  but  the  layers  of  the 
different    systems    cross    at    various    angles.      Be- 


8  MODERN    OPERATIVE    BONE    SURGERY. 

tween  these  layers  are  small  irregular  spaces 
called  lacunae.  These  lacunae  are  connected  by 
small  canals  or  canaliculi,  and  the  lacunae  nearest 
the  Haversian  canal  communicate  therewith,  by 
canaliculi;  in  other  words,  there  is  a  perfect  net- 
work of  small  and  large  lakes  and  canals  in  the 
shaft   of  long  bones. 

The  Haversian  canal  contains  blood-vessels  and 
nerves;  the  vessels  in  the  canals  are  covered  with 
endosteal  cells,  and  the  canals  themselves  are  lined 
with  the  same  cells.  The  space  thus  formed  is 
the  lymph  channel,  and  into  these  canals  the 
canaliculi  empty.  Thus,  an  indirect  connection  in 
the  periosteum  and  endosteum  is  formed.  In  each 
lacuna  is  a  bone-cell,  or  osteoblast — the  'important 
part  of  the   bone-graft. 

The  spaces  between  the  Haversian  systems  are 
occupied  by  the  interstitial  lamellae,  which  are 
short  and  very  irregular,  but  possess  lacunae  and 
canaliculi,  which  are  arranged  as  in  the  Haver- 
sian system.  The  lamellae  that  surround  the  mar- 
row cavity  are  irregular,  they  also  possess  lacunae 
and  canaliculi  and  the  all-important  osteoblasts, 
which  are  just  outside  of  the   endosteum. 

The  osteoblasts  are  irregular,  flattened,  stellate 
masses  of  protoplasm,  possessing  a  number  of 
processes.  The  protoplasm  is  granular,  and  each 
cell  contains  a  large  and  distinct  nucleus.  Osteo- 
blasts are  met  with  in  greatest  number  in 
the  deep  layers  of  the  periosteum,  and  in  the 
endosteum.  Cancellous  bone  is  found  in  irregular 
and   in    flat   bones,    and    it    forms   the    bulk   of    the 


HISTOLOGY    OF    PERIOSTEUM    AXD    BOXE. 


^=    ;u    v. 


o    o 


o    % 


10  MODERN    OPERATIVE   BONE   SURGERY. 

extremities  of  the  long  bones.  Its  anastomosing 
spicula  form  a  network  for  the  marrow.  It  con- 
tains lacunae,  and  canaliculi,  and  the  spicula  have 
a  fibrillar  structure.  In  the  ends  of  the  long 
bones  the  spicula  are  placed,  as  a  rule,  at  right 
angles  to  the  planes  of  articular  surface  (the  line 
of  greatest  pressure).  They  are  bound  together 
by  other  spicula  that  correspond  in  direction  to 
the  planes  of  the  articulation  (the  line  of  greatest 
tension).  The  nearer  the  marrow  cavity,  the 
heavier   and  stronger   these  spicula   are. 

The  blood-vessels  that  supply  the  cancellous 
bone  are  fewer  and  larger  than  those  that  supply 
the  compact  bone.  The  supply  for  both  is  derived 
from  the  periosteum,  whereas  the  marrow  derives 
it  principally  from  the  nutrient  artery.  This  ar- 
tery enters  through  the  nutrient  foramen,  usually 
located  near  the  center  of  the  shaft,  which  passes  ob- 
liquely through  to  the  medullary  canal.  There  the 
artery  gives  oft"  branches  towards  both  extremities, 
thus  forming  capillary  plexus  in  the  marrow,  and 
communicates  with  the  periosteal  vessels.  The  walls 
of  the  blood-vessels  in  bone  are  very  thin,  and 
the  current  very  slow ;  the  veins  are  given  exit  in 
three  places :  from  the  long  bone,  with  the  nu- 
trient artery,  and  at  the  articulating  extremities, 
and  from  the  compact  substance.  The  latter  two 
do  not  accompany  arteries,  but  immediately  after 
emerging  from  the  bone  they  have  numerous  valves. 
In  the  flat  and  cranial  bone  the  veins  are  numer- 
ous and  large.  The  nerve  supply  to  bone  is  very 
complete.      The    nerves    are    freely    distributed    to 


HISTOLOGY  OF  PERIOSTEUM  AND  BONE.     11 


Fig.  2.— Skiagraph  of  elbow  showing  fracture  of  the  internal 
and  external  condyles  of  humerus ;  with  ordinary  6-penny  fin- 
ishing nail  driven  through  each  condyle  into  lower  portion  of 
humerus,  holding  condyles  in  position;  also,  brachial  artery 
(injected  with  lead)  with  its  many  branches  around  elbow- joint. 
(/.  B.  Murphy.) 


12 


MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  3. — Illustrating  circulation  of  forearm,  wrist,  and  part 
of  hand.     (/.  B.  Murphy.) 


HISTOLOGY    OF    PERIOSTEUM    AND    BOXE.  13 


Fig_  4.— Beautifully  illustrating  circulation  of  pelvis  and  hip. 
(/.  B.  Murphy.) 


14 


MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  5. — Posterior  view  of  the  lower  portion  of  leg  and  foot. 
Also  illustrating  the  posterior  tibial  and  peroneal  arteries,  their 
position,  and  the  branches  given  off  from  them. 


HISTOLOGY   OF    PERIOSTEUM   AND    BONE.  15 

the  periosteum,  and  some  of  the  fibers  terminate 
in  this  structure  as  pacinian  corpuscles.  Nerves 
accompany  the  nutrient  arteries  into  the  interior 
of  the  bone,  and  also  reach  the  marrow  from  the 
periosteum  by  way  of  Volkmann's  and  Haversian 
canals.  They  very  thoroughly  supply  the  coats 
of  the  arterials,  and  ramify  about  the  osteoblasts. 
Articulating  surfaces,  as  well  as  bone-tissue,  are 
most  completely  supplied  with  nerves.  In  severe 
injury  to  bone  or  joint,  great  shock  follows,  on 
account  of  the  destruction  of  nerve-tissue. 

In  studying  the  elements  histologically  of  the 
periosteum,  it  must  be  studied  in  its  proper  rela- 
tion to  the  compact  bone,  as  well  as  when  it  is 
stripped  from  said  member.  Not  only  is  it  neces- 
sary to  examine  the  periosteum  intact,  and  that 
stripped  from  said  member,  but  much  depends 
upon  the  method  used  in  separating  it  from  the 
bone.  If  removed  with  a  quick  stroke  of  the 
periosteotome,  and  likewise  a  similar  strip  from  the 
same  location,  but  with  a  slow  raising  motion  of 
the  periosteotome,  and  each  strip  examined  micros- 
copically, the  variation  in  the  line  of  separation 
can  easily  be  demonstrated.  This  variation  be- 
comes more  marked  when  bones  of  different 
stages   of   development   are   studied. 

The  periosteum  is  a  membranous  coat  of  fib- 
rous tissue.  It  consists  of  an  outer  layer,  made 
up  of  interlacing  bundles  of  dense  fibrous  tissue, 
and  large  blood-vessels,  the  branches  of  which 
penetrate  into  the  underlying  compact  bone.  Di- 
rectly beneath  this,  and  in  contact  with  this  outer- 


Fig.  6. — Skiagraph  of  the  knee-joint  showing  the  popliteal 
artery  with  its  numerous  branches.  Star  indicates  a  large 
artery  entering  the  bone  near  the  upper  epiphyseal  junction. 
(/.  B.  Murphy.) 

(16) 


HISTOLOGY  OF  PERIOSTEUM  AND  BONE.     17 

most  layer,  is  a  firm  fibro-elastic  stratum,  which 
varies  with  the  age  of  the  individual.  In  adult 
bone  it  is  closely  attached  and  firmly  adherent  to 
the  surface  of  the  bone;  beneath  this  latter  stratum 
there  is  a  periosseous  or  cambium  layer  of  tissue 
consisting  of  small  vessels,  numerous  small  cells, 
and  fine  connective  tissue  fibrils — the  subperiosteal 
areolar  tissue  of  Macewen. 

The  cellular  elements  are  profuse  in  young  or 
developing  bone,  and  are  easily  divided  into  two 
distinct  types — an  outer  layer  of  cells,  with  plate- 
like nuclei  closely  packed  together,  and  an  inner 
layer,  consisting  of  small  oval  nuclei.  These  cells 
with  plate-like  nuclei  are  similar  to  those  found 
in   the   perichondrium   of   true   cartilage. 

These  two  types  of  cells  are  probably  dor- 
mant osteoblasts    (Haas). 

Microscopically,  there  is  no  demonstrable  line 
of  separation  between  the  periosteum  and  com- 
pact  bone. 

The  histological  components  of  the  stripped 
periosteum  vary  with  the  method  of  stripping,  as 
previously  stated,  definitely  proving  that  there  is 
no  distinct  line  of  cleavage. 

Again  repeating,  one  specimen  stripped  slowly 
with  a  blunt  instrument  will  contain  cellular  ele- 
ments not  present  in  a  specimen  stripped  quickly, 
or  with  a  sharp  osteotome. 

About  1740  Duhamel  brought  forth  the  first 
systematic  work  on  the  role  that  the  periosteum 
plays  in  the  repair  of  bone,  and  was  the  origi- 
nator   of    the    generally    accepted    modern    theory. 


18  MODERN    OPERATIVE    BOXE    SURGERY. 

It  was  his  belief  that  the  periosteum,  intact,  pro- 
liferated and  became  thickened  about  a  fracture, 
and  formed  the  callus  by  throwing  out  new  tissue. 
He  was  also  the  first  to  define  and  use  the  term 
"cambium  layer",  of  the  periosteum,  which,  since 
the  writing  of  Macewen,  has  become  recognized 
as  the  all-important  bone-growing  element  of  that 
member,  possessing  as  it  does,  when  removed  in  a 
certain  manner,   a  great  many  osteoblasts. 

Over  1 20  years  later  appeared  the  great  and 
important  work  of  Oilier  (1865),  which  has  with- 
stood the  test  of  time,  and  remains  today  the 
principal  foundation  of  all  exact  knowledge  of  the 
growth  of  bone.  His  work  was  so  thorough  that 
his  conclusions  have  attained  an  almost  unassail- 
able position.  He  proved  the  regeneration  of 
bone  from  periosteum  intact,  in  every  possible 
way,  and  ever  since  his  day  this  membrane,  in  its 
normal  position,  has  been  regarded  as  one  of  the 
most  important  vital  tissues  of  bone.  Nearly 
half  a  century  has  elapsed  since  Oilier' s  treatise, 
and  during  this  period  practically  the  whole  of 
modern   surgery  has   arisen. 

As  previously  stated,  it  is  evident  that  the 
periosteum  is  a  direct  derivative  of  the  chondro- 
blasts;  in  the  regeneration  of  bone  the  osteoblasts 
tend  to  revert  to  the  chondroblastic  type,  which 
is  shown  by  the  formation  of  cartilage  and  bone 
at  the  same  time  in  the  early  stages. 

In  the  regeneration  of  cartilage  there  is  a  re- 
version of  the  chondroblasts  to  the  connective-tis- 
sue  type   of   the   cells.      After    the   periosteum   has 


HISTOLOGY    OF    PERIOSTEUM    AND    BONE.  19 

proliferated  into  cartilage,  it  is  rapidly  trans- 
formed, either  directly  or  indirectly,  by  some 
specific  influence,  perhaps  of  a  chemical  or  phys- 
ical nature,  into  bone.  The  cartilage,  on  the 
other  hand,  some  of  it,  continues  to  grow  as  car- 
tilage, but  it  also  may  later  be  changed  into  bone, 
as  in  old  age.  The  growing  and  determining 
force  is  the  same  as  that  which  is  fundamental  to 
all  growing  conditions,  and  is  dependent  upon  a 
specific  property  of  the  cell,  which  determines  the 
character  of  the  tissue  to  be  formed. 

By  carefully  studying  the  voluminous  literature, 
and  reviewing  the  methods  of  experimentation,  the 
question  arises  whether  all  the  investigators  have 
included  or  excluded  the  same  components,  and 
what   constitutes   the   periosteum. 

Are  the  constituent  components  of  the  perios- 
teum constant,  or  are  they  subject  to  extensive 
variations,  either  numerically  or  in  type  and  ar- 
rangement  of   cellular    elements? 

On  account  of  the  utter  confusion  which  has 
arisen  concerning  the  exact  components  of  the 
periosteum,  I  shall  give  a  concise  description  of  its 
histological   activity   and   change   of   same. 

The  histological  structure  of  the  periosteum 
differs  in  its  component  constituents  at  different 
stages  of  development  of  the  body.  During  the 
stage  of  developing  and  growing  bone  the  perios- 
teum apparently  contains  an  active  third  layer,  or 
a  periosseous  layer,  in  which  is  found  the  fine 
connective-tissue  fibrils,  numerous  small  blood-ves- 
sels,  and   rows   of   small   cells,    the   osteoblasts. 


20  MODERN*    OPERATIVE    BOXE   SURGERY. 

The  term  periosteum,  as  generally  used,  is 
understood  to  be  the  periosteum  from  a  surgical 
standpoint.  As  such,  it  is  considered  as  the  mem- 
brane which  remains  after  a  careful  subperiosteal 
resection  of  the  underlying  bone,  special  care  be- 
ing exercised  that  no  bone  elements  are  left 
behind.  Moreover,  it  is  definitely  known  that  the 
periosteum,  in  different  stages  of  bone  develop- 
ment, contains  special  cellular  elements  in  greater 
or  lesser  number.  These  cellular  elements  are 
also  increased  by  toxic,  chemical,  or  mechanical 
causes.  Therefore,  it  will  be  expected  that  in  ex- 
periments produced  with  such  a  varying  structure 
as  the  periosteum,  although  all  other  details  were 
identically  carried  out,  the  results  would  be  at  a 
greater  or  lesser  variance  with  each  other,  even 
so    far    as    absolutely    contradictory    results. 

The  gross  anatomy  of  the  periosteum  is  a 
dense  fibrous  tissue  membrane,  completely  sur- 
rounding and  adhering  to  the  surface  of  the  bone, 
except  at  the  ends  or  articulating  surfaces,  where 
the  bone  is  covered  by  cartilage.  At  the  location 
of  the  tendon  attachment,  the  periosteum  becomes 
a  part  of  structure.  Many  blood-vessels  traverse 
the  periosteum,  and  enter  the  compact  bone 
through  Yolkmann's  canals.  "When  it  is  stripped 
from  the  living  bone  many  bleeding-points  are 
seen,  which  mark  the  site  of  the  entrance  of  these 
blood-vessels. 

Blood-vessels  from  the  periosteum  penetrate 
compact  bone,  and  reach  the  marrow  substance, 
communicating    with    branches    from    the    nutrient 


HISTOLOGY  OF  PERIOSTEUM  AND  BONE.     21 

artery.  The  periosteum  also  furnishes  the  blood 
supplied  to  the  cancellous  bone,  branches  of  which 
ramify  in  the  cavities  of  the  spongy  part  or  parts 
of   the   bone. 

After  a  thorough  investigation,  the  author  has 
come  to  the   following  conclusion: 

i.  That  the  periosteum  in  itself  has  no  osteo- 
genetic  power,   outside  of  the  adhering  osteoblasts. 

2.  By  the  removal  of  the  periosteum  from  a 
bone-graft,  a  great  number  of  osteoblasts  on  the 
surface  of  the  bone  are  removed  and  destroyed, 
thereby  reducing  the  osteogenetic  function  of  the 
graft  very  greatly. 

3.  That  if  the  periosteum  is  left  intact  on  the 
transplant,  it  supplies  nourishment  by  the  blood 
supply  to  the  osteoblasts  that  come  in  contact 
with,  and  just  beneath,  the  periosteum,  and  cause 
them    to    live,    thereby    stimulating    osteogenesis. 

4.  That  the  endosteum  supplies  nutrition  to  the 
osteoblasts  on  the  inner  surface  of  the  bone,  or 
that  are  nearby,  or  that  come  in  contact  with  the 
endosteum,  because  of  the  thorough  blood  supply 
of  the   endosteum. 

5.  That  if  the  endosteum  is  removed  from  the 
transplant,  a  number  of  osteoblasts  on  the  inner 
surface  of  the  bone  are  destroyed,  with  the  blood 
supply,  thereby  reducing  the  osteogenetic  function 
of   the   graft. 

6.  That  by  leaving  intact  both  periosteum  and 
endosteum  we  preserve  the  blood  supply,  thereby 
giving  nutrition  to  the  cells'  that  are  responsible 
for   the   regeneration   of   bone  and    nutrition    which 


22  MODERN    OPERATIVE   BONE   SURGERY. 

is    responsible    for   the    apparent   life   of    the    graft 
or  transplant. 

7.  Bony  protuberances,  condyles,  etc.,  detached 
from  all  tissue  save  the  periosteum,  unite  like 
free   autogenous   grafts    covered   with   periosteum. 

8.  Detached  bone,  protuberances,  or  condyles, 
with  healthy  periosteal  covering,  and  attached 
more  or  less  to  other  tissues,   continue  to   live. 

9.  By  using  autogenous  bone-grafts,  if  good 
apposition  is  obtained,  we  have  a  very  small  cal- 
lus, as  small  as  in  simple  fractures,  with  good 
apposition. 

10.  The  autogenous  graft  seems  to  live,  but 
in  reality  it  does  not;  the  trabecular  are  gradually 
replaced  by  bone  growing  inward  from  the  vas- 
cular spaces  between  them,  while  the  cartilage 
continues  to  live,  and  to  a  limited  extent  aids  in 
the   formation  of  the  new  bone  adjacent  to   it. 

11.  The  principal  replacement  of  bone  in  the 
trabecular  takes  place  directly  from  the  bone-cells, 
without  the  preliminary  formation  of  cartilage; 
and  the  dead  portion  of  the  trabecular  are  ab- 
sorbed in  a  line  immediately  adjacent  to  the  new 
growing  bone,  without  the  addition  of  special 
cells. 


CHAPTER   III. 

General  Considerations. 

functions  of  the  periosteum. 

It  is  very  evident  that  the  periosteum  has 
four  distinct  functions:  (i),  nutrition;  (2),  pro- 
tection; (3),  a  limiting  membrane;  (4),  that  of 
strengthening   and   fortifying. 

In  an  article  in  the  "Journal  of  Surgery, 
Gynecology  and  Obstetrics,"  of  May,  19 13,  Murphy 
stated:  "The  bone-graft,  per  se,  does  not  possess 
any  osteogenetic  power,  and  merely  serves  as  an 
osteogenetic  purpose.  The  regenerative  force  is 
supplied  by  osteogenetic  cells  found  normally  in 
the   Haversian   canal  and   lacunas   of   living  bone." 

One  of  the  important  recent  contributions  is 
that  of  Auxhausen  (1898).  It  is  readily  seen 
that  he  assumes  the  position  that  neither  bone 
alone,  nor  the  periosteum,  per  se,  is  osteogenetic: 
some  of  the  bone  dies,  but  a  portion  of  it  retains 
its  vitality;  the  periosteum  and  marrow  substance 
remain    alive,    and   produce   new   bone. 

Macewen  summarizes  the  function  of  the 
periosteum  as  follows:  "The  periosteum  is  of 
great  use  in  limiting  within  specific  boundaries  the 
distribution  of  the  osteoblasts,  and  preventing 
them,  during  the  evolutionary  period,  from  being 
scattered  into  soft  tissues,  where  their  presence 
would    be    prejudicial    to    the    functions    of    these 

(23) 


24  MODERN    OPERATIVE   BONE   SURGERY. 

parts.  In  the  loose  areolar  tissue  existing  between 
the  periosteum  and  the  bone,  the  osteoblasts  find 
nutriment  for  their  growth,  and  space  to  re- 
generate." 

Haas  concluded  "that  the  periosteum,  especially 
in  the  presence  of  blood-clot,  has  the  power  to 
regenerate  bone;  that  the  regeneration  of  the  bone 
never  formed  excepting  when  periosteum  was 
present."  In  a  recent  article  he  stated  "that  it  is 
apparent  from  his  studies  that  periosteum  is  very 
actively  concerned  in  the  regeneration  of  bone. 
There  is  at  first  a  proliferation  of  all  its  cellular 
elements  to  produce  a  cartilaginous  material,  which 
in  turn  is  changed  into  bone." 

Groves  states  "that  every  practical  worker  on 
the  subject  has  endorsed  the  opinion  that  a  living 
bone  of  the  same  species  gives  much  quicker, 
stronger,  and  more  certain  results  than  dead  bone, 
or  than  that  taken   from  any  other   species." 

John  B.  Murphy  states  that  in  order  to  achieve 
the  best  results  in  the  work  of  bone-grafting  and 
bone-transplantation  we  must  observe  or  keep  in 
mind  the  following  rules: — 

i.  (a)  "Normal  periosteum  completely  detached 
from  bone  transplanted  into  a  fat  or  muscle-tissue 
bed,  in  the  same  individual,  if  he  be  young,  may 
produce  a  permanent  bone  deposit,  but  only  if 
osteoblasts  remain  attached  to  the  lower  layer  of 
the  periosteum.  The  periosteum  of  itself,  is  not 
osteogenetic ;  it  is  rather  a  limiting  membrane, 
and  therefore  it  is  of  advantage  to  transplant  it 
with   the   bone,   although   it   is   not   essential   in   all 


FUNCTIONS    OF    THE    PERIOSTEUM.  25 

cases  to  do  so.  (b)  Normal  periosteum,  trans- 
planted into  another  individual  or  animal  of  the 
same  species,  and  under  the  same  condition, 
rarely,  if  ever,  produces  a  permanent  bone  de- 
posit. Any  bone  that  is  formed  from  such  perios- 
teum will,  sooner  or  later,  be  absorbed.  The 
osteogenetic  effort  of  this  periosteum  is  early  ex- 
hausted, (c)  Normal  periosteum  transplanted  into 
another  species  never  produces  a  permanent  bone 
deposit. 

2.  Strips  of  normal  periosteum  raised  from  the 
bone  detached  at  one  end,  but  left  attached  to  the 
bone  at  the  other  end,  if  turned  out  into  the  sur- 
rounding tissues,  usually  have  bone  produced  on 
the  under  surface  at  the  osteoperiosteal  angle,  but 
not  unless  there  are  osteoblasts  attached  to  it. 
This  is  an  etiologic  factor  of  many  of  the  ex- 
uberant calluses  in  fractures  in  the  neighborhood 
of  joints.  The  periosteum  and  some  of  the  osteal 
cells  are  torn  loose  by  the  muscular  contractions 
at  the  muscle  attachments,  or  elevated  by  the 
fracture,    and   these   develop   traumatic   exostoses. 

3.  Normal  periosteum  transplanted  into  other 
individuals  or  animals  of  the  same  species,  and 
contacting  at  one  end  with  exposed  or  freshened 
bone,  rarely,  if  ever,  produces  permanent  bone, 
even  for  a  small  extent,  at  its  basal  attachment, 
and   never   produces   bone   for   its   full   length. 

4.  When  bone  with  its  attached  periosteum  is 
transplanted  into  muscles,  fat  or  other  soft  tis- 
sues, in  the  same  individual,  and  free  from  bony 
contact,    it    may    for    a    very    brief    period   of    time 


26  MODERN    OPERATIVE   BONE   SURGERY. 

show  osteogenetic  powers,  but  eventually  the  for- 
mation of  the  new  bone  ceases,  and  all  of  the 
bone  is  absorbed,  except  in  the  cases  of  very 
young  children  or  infants.  When  transplanted 
into  another  species  it  is  always  absorbed. 

5.  Free  bone,  from  which  the  periosteum  has 
been  detached,  when  transplanted  into  muscle 
or  other  soft  tissues,  always  dies,  and  is  ultimately 
absorbed. 

6.  Bone,  with  or  without  periosteum,  trans- 
planted in  the  same  individual,  and  contacting 
with  other  living  osteogenetic  bone  at  one  or  both 
ends,  always  becomes  united  to  the  living  frag- 
ments, and  acts  as  a  scaffolding  for  the  produc- 
tion of  new  bone  of  exactly  the  same  size  and 
shape  as  the  original  bone,  provided  the  most  per- 
fect asepsis  is  maintained.  This  new  bone  sub- 
sequently increases  to  such  a  size  as  is  necessary 
to  give  the  support  required  by  nature  in  the  ex- 
tremity in  which  it  has  been  placed.  It  acts  as  a 
scaffold  for  the  production  of  new  bone,  but  al- 
lows the  osteoblasts,  which  are  normally  found  in 
the  Haversian  vessels,  to  travel  into  the  Haver- 
sian canals  of  the  transplant.  When  one  end  of 
such  a  transplanted  piece  of  bone  projects  into  a 
joint,  and  when  it  is  surrounded  by  the  original 
joint  capsule,  the  normal  conformation  of  the  bone 
end  in  the  joint  is  reproduced  almost  in  its  en- 
tirety, such  as  the  head  of  the  tuberosities  of  the 
humerus,  and  the  upper  extremities  of  the  femur, 
including  the  trochanters,  provided  the  muscle 
stumps   are  fixed  to  the  transplant  at  the  time  of 


FUNCTION   OF   THE   TRANSPLANT.  27 

operation,  in   about   their   normal   anatomic  relation 
with  sutures. 

7.  The  transplant,  no  matter  how  small  or 
how  large  it  may  be,  is  always  ultimately  ab- 
sorbed. It  is  my  conviction  that  its  role  in  the 
reproductive  process  is  merely  that  of  a  mechan- 
ical support  from  the  Haversian  blood-vessels  and 
the  living  osteogenetic  cells  as  they  advance  from 
the  living  bones  at  both  ends  and  pass  through 
the  Haversian  canals,  canaliculi,  and  lacunae,  of 
the  transplant.  Xew  lamellae  are  deposited 
around  the  new  capillaries,  and  these  lamellae  ad- 
just themselves  in  the  graft  in  such  a  manner 
that  a  firm  bony  union  is  formed,  and  the  con- 
tinuity of  the  bone  into,  or  on  to,  which  the  trans- 
plant has  been  placed,  is  re-established,  and  to 
such  a  degree  as  to  give  sufficient  support  to  the 
limb  before  the  transplant  is  entirely  replaced  by 
new  bone  or   the  transplanted  bone   is   absorbed. 

FUNCTION    OF    THE    TRANSPLANT. 

We  have  had  the  opportunity  of  observing 
that  ultimately  all  of  the  transplant  disappears. 
As  the  new  lamellae  are  formed  by  the  osteoblasts, 
the  osteoclasts  eventually  dispose  of  the  transplant, 
and  this  building  up  and  tearing  down  process  by 
the  osteoblasts  on  the  one  hand  and  by  the  osteo- 
clasts on  the  other,  keeps  pace.  As  rapidly  as 
new  bone  is  formed  in  and  around  the  trans- 
plant, the  old  bone  is  absorbed. 

"The  graft,  per  se,  does  not  possess  any  osteo- 


28  MODERN    OPERATIVE    BONE    SURGERY. 

genetic  powers :  it  merely  serves  as  an  osteo- 
genctic-conductive  purpose"  (Murphy).  The  re- 
generative force  is  supplied  by  the  osteogenetic 
cells  found  normally  in  the  Haversian  canals,  and 
lacunae  of  living  bone.  However,  in  order  that 
this  new  formation  of  bone  may  be  made  possible, 
the  transplant  or  graft  of  bone  is  an  absolute 
necessity. 

It  is  a  well-known  fact  that  unless  the  graft  is 
firmly  contacting  with  living  bone  the  osteogenetic 
cells  will  not  pass  over  from  the  living  bone,  or 
give  stimulus  to  the  transplant,  and  vice  versa. 
I  have  had  one  case  in  my  clinical  experience  in 
which  that  was  demonstrated.  One  end  of  the 
transplant  only  was  firmly  contacted  with  living 
bone,  and  here  a  firm  solid  bony  union  took  place. 
The  other  end  of  the  transplant  had  partly  freed 
itself  from  its  contact  with  the  living  bone,  so 
that  it  was  loose,  and  not  firm;  while  there  was 
some  callus  formation  at  this  end  of  the  trans- 
plant,  there   was   no   other   effort  at  bone   union. 

8.  I  have  found  from  extensive  study  of  skia- 
grams of  cases  in  which  bone-transplantation  has 
been  done  that  the  graft  increases  in  size  on  the 
surface  in  the  same  manner  as  the  deposits  of 
bone  lamellae  take  place  in  the  normal  growth  of 
bone;  that  is,  by  piling  up  of  the  deposits  of  bone; 
in  layers  beneath  the  newly  formed  periosteum. 
Any  osteogenetic  force  which  may  be  possessed  by 
the  periosteum  is  imparted  to  the  periosteum  by 
such  osteogenetic  cells  as  may  be  attached  to  its 
under  surface. 


FUNCTION  OF  THE  TRANSPLANT.         29 

9.  When  bone  is  transplanted  to  supply  a  de- 
fect in  that  portion  of  bone  which  enters  into  the 
formation  of  a  joint,  such  as  the  upper  end  of 
the  humerus,  or  the  upper  end  of  the  femur,  the 
muscles  in  the  vicinity  of  that  joint  should  be 
fixed  to  the  transplant,  or  firmly  sutured  around 
the  transplant,  in  the  same  relation  as  exists  nor- 
mally, if  muscular  control  and  muscular  fixation 
of  both  has  taken  place.  The  musculotendinous 
attachments  of  the  muscles  should  be  sutured  ac- 
curately around  the  graft  at  the  point  of  desired 
union. 

10.  Bone  covered  at  the  end  by  cartilage  and 
at  the  sides  by  periosteum,  such  as  the  phalan- 
geal bones,  even  when  contacting  with  living  bone, 
dies,  and  is  entirely  absorbed.  The  interposition 
of  any  tissue,  either  cartilage  or  periosteum,  be- 
tween the  surface  of  living  bone  will  effectually 
prevent  the  passage  of  the  Haversian  vessels  and 
the  osteogenetic  cells  from  one  bone  into  the 
other,  and  failure  of  union  is  inevitable.  That 
is  a  positive  law.  Regeneration  can  take  place 
only  when  living  bone  contacts  with  living  bone, 
without  any  interposing  substance,  so  that  the 
osteogenetic  cells  may  find  their  way  out  from  the 
bone   into   the   transplant. 

The  essential  feature  to  be  borne  in  mind  in 
carrying  out  this  work  is,  that  the  transplant  must 
contact  with  living  bone,  at  at  least  one  end.  If 
the  epiphysis  of  the  long  bone  has  been  destroyed, 
the  bone  will  not  grow   in  length   from  the  trans- 


30  MODERN    OPERATIVE   BONE   SURGERY. 

plant,  at  the  point  of  epiphyseal  absence,  unless 
an  epiphysis    is    transplanted    thereto. 

If  the  entire  shaft  of  the  long  bone,  such  as 
the  tibia,  humerus,  radius,  or  ulna  be  absent,  then 
the  bone  must  contact  with  the  neighboring  bone, 
laterally,  or  at  one  end  or  the  other  of  the  ex- 
tremity across  the  normal  line  of  the  joint,  in 
order  to  get  an  osteogenetic  supply,  as  in  the 
case  of  absence  of  the  tibia  the  graft  articulates 
with  the  neck  of  the  femur,  or  astragalus.  Sub- 
sequently an  arthroplasty  can  be  done  to  give  the 
patient  a  movable  joint. 

The  indications  for  bone  transplantation  are  as 
follows : 

i.  To  correct  the  deformities  resulting  from 
defective  development,  such  as  aplasia  of  the 
bones  of  the  extremities  of  the  nasal  bones,  and 
of    the    mandible. 

2.  To  effect  union  in  ununited  fractures,  no 
matter  how  remote  the  occurrence  of  the  fracture, 
no  matter  whether  of  congenital  or  purely  trau- 
matic origin. 

3.  To  restore  or  supplant  such  parts  of  the 
bone  as  may  have  been  dislodged  or  destroyed  by 
fractures,  as  in  the  case  of  fracture  through  the 
head  of  the  anatomic  neck  of  the  humerus  or 
femur,    etc. 

4.  To  replace  bone  which  has  been  removed 
because  of  its  having  been  the  seat  of  non- 
malignant  neoplasm,  such  as  a  cyst,  a  myeloma. 
or   osteitis   fibrose   cystic,    etc. 

5.  To  replace  bone  which  was  removed  because 


FUNCTION    OF   THE   TRANSPLANT.  31 

of  having  been  the  seat  of  encapsulated  malig- 
nant disease,  such  as  chondrosarcoma,  or  fibro- 
sarcoma. 

6.  To  replace  bone  which  has  been  destroyed 
by  an  infection,  such  as  osteomyelitis,  tuberculosis, 
etc. 

Dr.  Albee  states  that  he  has  repeatedly  and 
successfully  used  bone-grafts  for  spanning  through 
tuberculosis  of  the  ankle  and  knee-joints;  that  the 
cortical  bone-graft  has  always  withstood  pure 
tuberculous  infection,  providing  it  has  satisfactory 
connections  with  healthy  bone  on  each  side  of  the 
infected  focus;  that  it  will  also  resist  attenuated 
pyogenic  infection  under  similar  conditions  has 
been  proved  by  experiments  conducted  by  Phe- 
mister  and  others,  in  both  surgical  and  laboratory 
work.  The  importance  of  this  inherent  germ- 
resisting  property  of  the  bone-graft  is  readily  ap- 
parent, in  that  it  doubly  assures  its  trustworthi- 
ness as  a  general  surgical  agent  (when  compared 
with  metal).  Especially  is  this  true  in  the  ap- 
plication to  compound  fractures  in  which  infection 
is  feared,  or  where  mild  infection  has  already 
occurred. 


CHAPTER  IV. 

The   Repair  of  Bone. 

A  wound  to  bone  is  caused  either  by  trans- 
verse or  by  longitudinal  stresses  producing  frac- 
tures or  fissures  of  bone-tissue,  or  in  perforating 
wound,  produced  by  bullets  or  sharp  missiles. 
The  injury  is  not  confined  to  the  bone  structure 
alone.  The  periosteum  is  usually  torn  across, 
or  raised  from  the  shaft  of  the  bone  by  a  separa- 
tion of  the  fragments  and  the  connecting  muscles, 
and  vascular  tissues  immediately  surrounding  the 
site  of  the  injury  are  damaged.  Only  in  simple 
and  fissured  fractures,  without  displacements  of 
fragments,  are  the  injuries  to  the  surrounding 
tissues  kept  within  moderate  bounds.  The  amount 
of  the  blood  that  exudes  into  the  surrounding 
structure  depends  upon  two  things:  (i)  the  den- 
sity of  the  tissue,  and  (2)  the  size  of  the  blood- 
vessels   injured. 

If  the  infiltrate  of  a  considerable  amount  of 
sanguineous  fluid  appears  some  distance  from  the 
point  of  fracture,  we  know  that  a  vessel  of  con- 
siderable size  has  been  injured.  The  amount  of 
blood,  however,  which  escapes,  as  a  rule,  is  slight, 
and  confines  itself  chiefly  to  the  medullary  canal. 
The  discoloration  of  the  skin  is  due  to  laceration 
of  the  capillaries  received  during  the  accident.  The 
destruction  of  tissue  in  compound  fractures  is 
(32) 


THE   REPAIR   OF   BONE.  33 

much  greater,  and  the  amount  of  blood  set  free  is 
naturally  more  abundant.  Reparative  changes  com- 
mence about  the  seat  of  fracture  a  short  time 
after  the  injury  is  produced.  Complete  restora- 
tion of  the  structure  may  ensue,  and  after  a  few 
months  scarcely  a  trace  of  the  injury  be  obtained. 

The  reparation  or  healing  of  fractures  is  not  a 
growth  of  bone-cells,  but  a  production  and  or- 
ganization of  new  tissue,  which  surrounds  the 
injured  parts  or  fragments,  and  is  derived  chiefly 
from  the  periosteal  covering  of  the  bone. 

I  will  consider  the  process  in  two  stages:  (i) 
the  formation  of  a  callus,  that  which  completes 
the  union  of  the  parts;  and  (2)  the  absorption 
of  the  redundant  portions  of  the  callus;  and  the 
ossification  is  completed  by  the  deposition  of  lime 
in  the  newly  formed  tissue.  However,  strictly 
speaking,  both  of  these  processes  in  some  degree 
go  on  simultaneously.  Within  a  week  or  ten  days 
after  the  occurrence  of  the  fracture,  calcium  salts 
are  deposited  in  the  newly  formed  osteoid  and 
cartilaginous  tissue.  As  previously  stated,  the 
periosteum  and  endosteum  play  a  very  active  part 
in  the  formation  of  the  callus,  which  unites  or 
cements  the  ends  of  the  bone.  The  callus  produced 
from  the  periosteum  is  termed  the  "periosteal  cal- 
lus"; that  from  the  endosteum,  the  "myelogenous 
callus",  while  the  new  tissue  which  lies  between  the 
ends  of  the  fragments  is  commonly  designated  the 
"intramedullary  callus". 

In  early  childhood  the  cartilage  which  exists 
at    the    epiphyseal    junction    is    capable    of    forming 


34  MODERN   OPERATIVE   BONE   SURGERY. 

callus.  A  large  callus  is  formed  in  fractures  of 
the  shaft  of  the  long  bone;  a  much  smaller 
growth  is  usually  seen  in  connection  with  fractures 
at  the  epiphyseal  ends  of  long  bones,  in  fractures 
of  the  body  of  the  vertebrae,  and  in  flat  bones 
of  the  pelvis  and  skull.  The  amount  of  callus 
formed  is  very  valuable,  and  partly  depends  upon 
the  condition  and  size  of  the  bone  fractured,  and 
the  form  of  the  injury.  For  instance,  in  frac- 
tures of  the  skull,  the  external  callus  can  scarcely 
be  designated  by  a  palpation;  however,  when  the 
displacement  of  the  fragment  is  considerable,  a 
very  large   callus   is   formed. 

Clinically,  the  regeneration  of  bone  is  an  ex- 
tremely important  matter,  and  it  is  well  to  appre- 
ciate that  the  regeneration  of  bone,  like  the  re- 
generation of  cartilage,  is  merely  the  regeneration 
of  a  somewhat  modified  connective  tissue,  as  pre- 
viously stated.  The  new  cells  in  each  are,  in  the 
earliest  stages,  exactly  like  the  fibroblasts.  This 
is  not  remarkable  when  we  remember  the  rela- 
tionship between  the  three  tissues;  cartilage  be- 
comes converted  into  bone;  the  periosteum  may 
give  rise  to  fibrous  tissues,  as  happens  when  a 
fibrous  union  occurs  instead  of  an  osseous.  Fur- 
ther, although  we  are  accustomed  to  speaking  of 
bone  arising  with  or  without  the  previous  inter- 
position of  cartilage,  both  kinds  of  bone  are 
actually  modified  connective  tissues,  and  no  dis- 
tinction is  to  be  made  in  their  form  of  regenera- 
tion. Regeneration  of  the  medulla  is  of  the  same 
order  as  that  of  the  periosteum.     The  long  bones 


THE   REPAIR   OF   BOXE.  35 

have  remarkable  qualities  of  regeneration.  In  the 
lamellae  of  the  bone  itself,  as  well  as  in  the 
periosteum  and  the  medulla,  there  is  constantly 
regenerative  changes  going  on,  and  old  bone  is  being 
replaced  by  new.  The  periosteum  and  endosteum 
play  their  part  in  these  changes;  in  fact,  all  these 
forces  which  build  up  the  bone  in  the  first  place  take 
part  in  regeneration  and  repair  after  injury  or 
destruction. 

Murphy  states  that  the  amount  of  growth  in 
a  bone  depends  on  the  need  of   it. 

According  to  Wolff's  law,  "every  change  in 
the  form  and  position  of  the  bones  or  of  their 
function  is  followed  by  certain  definite  changes  in 
their  internal  architecture,  and  by  equally  definite 
secondary  alterations  of  their  external  conforma- 
tion,   in   accordance   with   their   mechanical   laws". 

'The  keynote  of  all  bone  development  seems 
to  be  a  co-ordinate  arrangement  of  the  bone-cells 
in  lateral  and  end-on  relations  to  each  other, 
under  the  stimulus  of  pressure  and  strain  within 
certain   limits   of   intimate   capacity"    (Bond). 


CHAPTER  A'. 

Repair  of  Bone  in  Detail. 

The  softening  and  swelling  of  the  periosteum 
is  the  first  evidence  of  the  inflammatory  reaction, 
or  the  first  step  of  repair;-  here  we  notice  leuco- 
cyte migration  from  the  vessels,  the  endothelium 
of  which  is  markedly  swollen.  Proliferation  of  the 
connective  tissue  cells  begins  within  twenty-Tour 
hours.  A  soft  tissue  thus  produced  by  the  inner 
laver  of  the  periosteum  consists  at  first  merely  of 
a  very  vascular  connective  tissue,  containing  nu- 
merous spindle  or  irregular-shaped  cells,  termed 
osteoblasts,  which  lie  in  a  stroma  which  is  partly 
hyaline  and  partly  fibrous  tissue.  A  change  takes 
place  four  or  five  days  after  the  fracture  in  the 
fibrous  tissue,  resulting  in  the  formation  of  small 
masses  or  clumps  of  a  substance  resembling  bone, 
but  not  containing  calcium  salts — osseous  tissue. 
This  osseous  tissue,  as  it  is  called,  is  ultimately 
changed  into  bone.  Any  excesses  remaining  are 
finally  removed  by  the  osteoclasts.  The  connective 
tissues  in  the  meshes  or  interstices  become  altered 
by  a  marrow-like  substance.  The  hyaline  areas 
referred  to  above  develop  into  the  so-called  chond- 
roid  tissue,  or  into  true  cartilage.  The  amount  of 
cartilage  which  is  formed  in  fractures  is  largely 
governed  by  the  displacement;  where  apposition  is 
perfect,  we  find  very  little.  When  marked  defor- 
mity is  present  (Fig.  7)  a  greater  amount  of  car- 
(36) 


BONE   REPAIR   IN    DETAIL. 


37  $ 


Fig.  7 —Skiagraph  of  the  arm  showing  a  vicious  fracture  of 
humerus  near  the  junction  of  middle  with  the  lower  third.  Six 
months  after  accident.  Fairly  good  union,  notwithstanding  the 
overlapping  of  the  bones  and  deformity  existing. 


38  MODERN    OPERx\TIVE   BONE   SURGERY. 

tilage  is  formed,  and  this  cartilaginous  part  of  the 
callus  is  of  the  greatest  importance  in  the  final  con- 
struction of  bone,  which  cements  the  fragments. 
Again,  the  greater  portion  of  the  cartilage  is  pro- 
duced by  the  inner  layer  of  the  periosteum.  After 
the  cartilage  has  become  thoroughly  vascularized, 
ossification  takes  place  by   direct  transformation. 

Should  the  ends  of  the  bone  be  separated  by 
too  great  an  interval  to  permit  of  suitable  callus 
formation,  or  should  muscle  or  tendon  be  forced 
between  the  ends  of  the  fractured  bone,  or  if 
proper  immobilization  of  the  fragments  has  not  been 
obtained,  union  may  not  take  place  at  all,  or  there 
may   be    a   fibrous    union. 

Complicated  fractures,  such  as  compound-com- 
minuted, heal  in  a  manner  similar  to  those  of 
simple  variety,  providing  infection  does  not  occur. 
Should  infection  occur,  we  will  have  a  delayed  or 
very  imperfect  union,  which  is  caused  either  by 
thromboses  of  the  vessels  or  death  of  the  perios- 
teum, and  necroses  of  the  bone  may  follow.  The 
overabundant  granulation  tissue  which  follows  such 
condition,  is  liable  to  interfere  with  proper  callus 
formation.  Finally,  the  callus  that  is  produced  is 
more  abundant  than  is  necessary  for  the  proper 
union  of  the  fractured  bone.  Considerable  time 
after  the  repair  has  begun,  the  partial  ossification 
of  the  callus  has  occurred;  the  redundant  external 
and  internal  callus  begins  to  be  absorbed.  It  is 
generally  believed  that  the  absorption  is  accom- 
plished by  large  multinuclear  cells,  known  as 
osteoclasts. 


BONE   REPAIR   IN    DETAIL.  39 

Some  observers  are  inclined  to  regard  the 
osteoclasts  as  of  minor  importance  in  the  shrink- 
ing, and  consider  the  regressive  changes  in  the 
callus  as  a  type  of  diseased  atrophy,  or  resorption, 
due  to  general  ferment  of  the  tissue,  thus  restoring 
the  bone  to  practically  the  original  condition,  with 
possibly  the  following  exception:  a  slight  narrow- 
ing of  the  medullary  canal,  and  a  hardly  per- 
ceptible thickening  of  the  shaft;  the  redundant 
fibrous  callus  is  also  reduced  in  volume  by  granu- 
lar contraction  of  its  elements,  and  a  shrinkage  of 
its   blood   supply. 


CHAPTER  VI. 

The  Evolution  that   has  Taken   Place  in 
tlie  Treatment  of  Fractures. 

Great  advancements  have  been  made  in  the 
treatment  of  fractures  of  every  description  within 
the  last  ten  years,  and  much  credit  should  be 
given  Mr.  Lane  for  the  progress  of  asepsis  and 
the  most  perfect  operative  technic  he  has  de- 
veloped. Much  has  been  accomplished  in  bone 
surgery  since  Mr.  Lane's  initiative  work,  that 
hitherto  seemed  hopeless.  Within  the  last  few  years 
surgeons  have  been  considered  radical  who  have 
intervened  surgically  in  the  treatment  of  simple 
fractures.  On  the  other  hand,  I  have  known 
surgeons  with  little  judgment  or  surgical  skill, 
who  have  attempted  the  operative  treatment  of 
fractures,  and,  aside  from  frequently  infecting  the 
wound,  by  faulty  technic,  have  often  added  for- 
eign materials,  which  might  have  caused  suppura- 
tion  later. 

Reduction  of  fractures  by  manipulation  (closed 
reduction)  is  not  without  danger  to  vessels, 
nerves,  and  muscles,  and  in  many  cases  does  not 
attain  the  desired  end;  i.e.,  the  return  to  proper 
alignment,  or  normal  anatomical  relations.  For 
example,  take  the  usual  fractures  of  the  femoral 
shaft,  in  which  the  end-to-end  apposition  is  rarely 
obtained.  However,  this  is  only  one  of  many,  out 
(40) 


EVOLUTION  IN  TREATMENT  OF  FRACTURES.    41 


Fig.  8.— Fractured  neck  of  femur.  Two  12-penny  nails  are 
seen  driven  through  upper  end  of  femur,  through  neck,  into 
head  of  bone:  also  broken  wire  used  in  fastening  fragments 
together.     (/.  B.  Murphy.) 


42  MODERN    OPERATIVE    BOXE    SURGERY. 


Fig.  9. — Fracture  of  lower  end  of  humerus  near  elbow-joint, 
showing  considerable  deformity.  Skiagraph  taken  six  months 
after  accident.  Position  of  fragments  interferes  materially  with 
motion  of  elbow-joint. 


EVOLUTION  IN  TREATMENT  OF  FRACTURES. 


43 


Fio.  10 -Oblique  fracture  of  the  femur  near  junction  of  the 
middle  with  upper  third.  Tins  form  of  fracture  is  very  hard Jto 
hold  in  position,  and,  as  a  rule,  good  results  do  not  follow  the 
external  method  of  treatment. 


44  MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  11. — Fracture  of  the  humerus  near  juncture  of  middle 
of  lower  third,  of  six  months'  standing.  Bad  deformity,  with 
attempt  at  bony  union. 


EVOLUTION  IN  TREATMENT  OF  FRACTURES.    45 

of  a  large  proportion  of  fractures ;  there  is  a  cer- 
tain percentage  that  have  given  unsatisfactory  re- 
sults following  the  closed  method.  Then  such 
group.  I  believe,  should  be  subjected  to  the  open 
method,  and  to  anatomical  reduction  of  the  frag- 
ments. Aside  from  the  return  to  the  proper 
alignment,  there  should  always  be  considered  the 
question  of  joint  strain,  as  is  strikingly  seen  in 
special  work  more  than  in  general   surgery. 

The  general  surgeon  treats  his  common  frac- 
tures of  the  femur  in  the  usual  way  (closed 
method),  and  gets  union,  and  often  never  sees 
the  patient  again  after  bony  union  takes  place. 
Years  after,  the  orthopedist  is  consulted,  and  finds 
that  the  patient  is  suffering  with  scoliosis,  result- 
ing from  a  short  leg,  following  an  ill-treated 
fracture. 

In  a  young,  growing  child,  a  shortening  of 
three-quarters  to  an  inch  will  cause  joint-strain, 
which  results  in  the  development  of  structural  de- 
formity. Nevertheless,  the  general  surgeon  con- 
siders half-  or  three-quarters  of  an  inch  shorten- 
ing"   a    good    result. 


CHAPTER  VII. 

Operative  Treatment  of  Fractures, 
factors  to  be  accomplished. 

The  day  is  near  at  hand,  when  all  fractures  of 
the  femur  will  be  subjected  to  the  open  method 
(excepting  those  occurring  in  infancy),  for  in  the 
open  treatment  the  alignment  is  perfect,  and  we 
do  not  have  any  shortening,  providing  the  work  is 
done  correctly.  Up  to  the  time  Mr.  Lane  began 
insistently  to  champion  the  open  method,  also  the 
use  of  metallic  plates,  strong  prejudice  against  the 
open  treatment  existed.  This  was  created  partly 
by  the  results  obtained,  and  partly  by  tradition. 
Immediately  non-traumatic  and  strict  aseptic  sur- 
gery  became   recognized   as   all-important. 

At  present,  the  opinion  of  the  up-to-date  sur- 
geons who  are  doing  bone  work  is  a  unit  in  re- 
gard to  the  question  of  the  open  treatment  of 
simple  fractures.  The  open  treatment  of  frac- 
tures of  the  patella  (Fig.  12)  has  been  practised 
for  years;  gradually  this  effort  to  secure  not  only 
bone  union,  but  actual  approximation  of  the  frag- 
ments, has  been  accomplished.  These  attempts 
were  carried  to  fractures  of  the  olecranon  process 
(Fig.  13).  Since  the  perfection  of  bone  surgery 
technic  the  field  has  been  so  enlarged  as  to  in- 
clude every  one  of  the  long  bones  of  the  bodv,  in 
(46)  " 


OPERATIVE    TREATMENT    OF   FRACTURES. 


47 


Fig.  12. — Outlining  bone-inlay  used  to  hold  fragments  to- 
gether in  fracture  of  patella.  Also  shows  bone-pegs  in  position, 
giving  firmness  and  rigidity  to  the  transplant. 


Fig.  13. — Illustrates  the  author's  method  of  removing  the 
rectangular  dowel  from  the  distal  fragment  in  fracture  of  the 
olecranon  process,  driving  it  into  a  "tunnel"  made  in  end  of 
fragment  A  and  extending  into  fragment  B;  driving  graft  C 
into  position,  as  shown  by  dotted  lines  D.  Fastened  into  posi- 
tion by  bone-pegs. 


48  MODERX    OPERATIVE    BONE    SURGERY. 

which  reduction  is  either  difficult  or  impossible,  or 
in  which  the  fragments  cannot  be  kept  in  posi- 
tion   by   the    ordinary    methods. 

It  matters  not  what  mode  of  internal  fixation 
is  used,  whether  the  intramedullary  dowel  or  in- 
lay graft,  the  limb  should  be  firmly  immobilized 
with  plaster-of-Paris  cast  or  splints  in  as  nearly  a 
neutral  position  as  possible.  The  position  in 
which  the  limb  should  be  placed  will  cause  the 
relaxation  of  the  muscles,  which  have  a  displacing 
influence  in  said  fracture.  If  the  above  is  closely 
observed  and  followed  out,  the  intramedullary 
dowel,  inlay  graft,  or  neck  of  femur  spike,  will 
not  bend  or  break  during  the  period  of  postopera- 
tive fixation.  In  all  cases  of  persistent  non-union, 
whatever  the  contributing  cause  may  be,  whether 
syphilis  or  any  other  systemic  condition,  with  hid- 
den influences  producing  meager  callus  formation, 
such  conditions  should  be  treated  before  operative 
procedures   are  undertaken. 

Any  operation  for  the  reduction  of  simple  frac- 
ture, and  followed  in  the  majority  of  cases  by  an 
intramedullary  dowel  or  inlay,  is  a  step  which 
should  be  only  undertaken  if  the  surroundings  and 
facilities  for  an  aseptic  technic  are  perfect,  or 
nearly  so,  and  the  surgeon  is  equipped  with 
proper    instruments. 

Such  conditions  can  only  be  found  in  modern 
hospitals.  An  attempt  to  perform  such  operation 
without  the  proper  equipment,  surroundings,  and 
precautions,  means  infection,  which,  although  it 
may  not  prove  fatal,  will  jeopardize  the  usefulness 
of   the   limb. 


OPERATIVE    TREATMENT    OF    FRACTURES. 


49 


Fig.  14. — Pott's  fracture  with  internal  malleolus  broken  off; 
also,  fracture  of  fibula  about  two  inches  above  joint.  Ordinary 
10-penny  nail  driven  through  internal  malleolus  into  the  tibia, 
and  two  8-penny  nails  driven  through  fibula  into  tibia.     (/.  B. 

Murphy.) 


50  MODERN    OPERATIVE    BOXE    SURGERY. 

With  aseptic  surroundings  and  the  proper 
equipment,  in  experienced  hands,  danger  of  infec- 
tion is  no  greater  in  bone  work  than  it  would 
be  in  any  other  major   surgical  operation. 

The  extensive  and  accurate  use  of  the  X-ray 
has  undoubtedly  played  an  important  part  in  the 
development  of  the  tendency  to  open  up  simple 
as   well   as    complicated   fractures. 

Those  who  have  had  occasion  to  treat  a  great 
number  of  fractures,  and  have  had  the  privilege 
of  subjecting  them  to  X-ray  examinations  have 
found  that  the  radiograph  will  often  show  a 
marked  displacement  of  the  fragments;  so  great, 
in  fact,  that  one  would  expect  much  visible  and 
palpable  displacement  or  deformity,  but  by  ex- 
amination in  the  ordinary  method  we  are  often 
deceived.  Hence  the  X-ray  is  indispensable  to  the 
surgeon  who  wishes  to  get  the  best  possible  re- 
sults, and  who  wishes  to  be  honest  with  his  pa- 
tients and  himself  as  to  the  real  condition  existing. 

The  advent  of  open  treatment  has,  however, 
brought  many  disastrous  results,  first,  by  bad 
technic;  second,  by  introducing  foreign  material; 
but  with  perfect  asepsis,  and  equal  technic,  we 
can  safely  expose  the  ends  of  the  fractured  bones, 
and  skillfully  adjust  them,  with  less  danger  tO' 
the  surrounding  parts,  than  by  reducing  them  by 
the  closed  method.  A  surgeon  thus  well-founded 
has  the  moral  right  to  treat  any  fracture  by  the 
open  method,  and  does  not  thereby  add  to,  but 
deducts  from,  the  existing  danger.  This  un- 
doubtedly is  the  greatest  advance  that  has  ever 
been  made  since   the   advent   of  bone-plating. 


CHAPTER  VIII. 

The    Use   of    Foreign    Material. 

The  application  of  a  metallic  plate  to  broken 
bone  requires  a  special  technic;  infection  has  oc- 
curred in  a  varying"  percentage  of  cases,  with 
serious  inhibitory  effects.  The  metallic  plate  or  any 
foreign  body,  placed  over  the  fractured  ends  of 
a  bone,  prevents  the  formation  of  callus  over 
such  area,  also  invites  infection.  Is  it  any  wonder 
that  such  a  great  number  of  failures  have  followed? 

Foreign  bodies  such  as  nails,  screws,  and  wire 
are  tolerated  in  the  human  body  with  surprisingly 
little  reaction;  they  remain  firm  for  a  while,  pro- 
viding the  technic  is  perfect  during  application, 
but  sooner  or  later  we  have  rarefaction  and  ab- 
sorption of  the  bone  that  comes  in  contact  with 
said  foreign  material,  with  mild  infection  follow- 
ing,  which  may  result   in   caries   or   necrosis. 

Martin  states:  "It  is  noteworthy  that  union  is 
usually  delayed  by  the  Lane  plate;  that  the  time  of 
treatment  repair  as  a  rule,  is  not  shortened;  that  the 
results  are  not  uniformly  good,  but,  taken  as  a 
whole,  they  are  infinitely  better  than  could  have 
been  secured  by  other  than  operative  means.  There 
seems  to  be  a  relation  between  the  size  of  the 
internal  (metal)  splint  and  the  promptness  of 
final  union.  In  other  words,  we  have  felt  that 
the  less  foreign  matter  we  have  put  into  the  wound, 

(51) 


MODERN*    OPERATIVE    BONE    SURGERY. 


Pig.  15. — Fracture  of  upper  third  of  humerus  just  above  in- 
sertion of  deltoid  muscle.  Skiagraph  shows  Lane  plate,  which 
was  applied  six  months  before  taking  of  picture.  No  union 
between  ends  of  fractured  bone. 


THE    USE    OF    FOREIGN    MATERIAL. 


53 


Fig.  16. — Same  as  Fig.  IS.    Lane  plate  has  been  removed,  and 
intramedullary  dowel  applied.    A  perfect  result  followed. 


54  MODERN    OPERATIVE   BONE   SURGERY. 

the  quicker  it  gets  well."  It  is  a  fact  that  any 
foreign  material  (Fig.  17),  (metal  plates,  ivory 
or  iron  pegs,  silver  or  copper  wire,  etc.),  in  con- 
tact with  bone  will  eventually  set  up  an  irrita- 
tion which  is  followed  by  a  rarefaction  and  ab- 
sorption of  the  bone;  and  in  some  cases,  osteo- 
myelitis, caries  or  necrosis  follows.  We  notice  in 
some  cases  (as  seen  in  Fig.  iSA)  all  screws 
are  loosened,  and  the  presence  of  the  plate 
has  caused  considerable  absorption  of  both  ends  of 
the  bone  by  its  contact.  This  is  a  common  occur- 
rence; and  in  a  very  large  percentage,  where  the 
Lane  plate  has  been  applied,  removal  is  necessary, 
not  at  any  particular  time,  for  years  may  elapse 
before  any  disturbance  occurs.  Then  the  patient 
is  forced  to  seek  relief,  and  the  consulted  surgeon 
finds  that  he  is  compelled  to  remove  the  plate  or 
foreign  material  (Fig.  18 A)  with  one  or  more  of 
the  above  changes  present.  Also  in  old  cases  of 
excision  of  the  knee-joint,  in  which  silver  or  cop- 
per wire  has  been  used,  discharging  sinuses  have 
opened  ten  or  fifteen  years  after  the  insertion  of 
the  wire. 

There  is  no  question  but  that  the  presence 
of  a  metallic  plate,  instead  of  stimulating  osteo- 
genesis, retards  it;  therefore  autogenous  bone- 
grafts  with  periosteum  are  in  great  favor,  for  not 
only  do  they  produce  bone  themselves,  but  they 
stimulate  the  bone  ends,  with  which  they  come  in ' 
contact,  to  a  more  active  osteogenesis.  There  forms 
an  immediate  adhesion  between  the  graft  and  the 
fractured    ends,    and    as    time    elapses    it    becomes 


THE   USE   OF   FOREIGN    MATERIAL. 


55 


Fig.  17.— Same  as  Fig-.  14.  Side  view  of  Pott's  fracture  in 
a  young  lady  18  years  of  age,  showing  three  nails  in  position. 
One  10-penny  ordinary  spike  driven  through  the  internal  mal- 
leolus up  into  tibia,  and  two  ordinary  8-penny  nails  driven 
through  lower  fragment  of  fibula  into  tibia.     (/.  B.  Murphy.) 


56  MODERN    OPERATIVE    BONE    SURGERY. 

firmer  and  firmer  united,  until  we  have  a  perfect 
bone-union.  And  furthermore,  unlike  a  foreign 
material,  the  graft  has  certain  bacteria-resisting 
properties. 


Fig.  18. — A,  fracture  of  both  bones  of  forearm.  Skiagraph 
shows  Lane  plate,  applied  five  months  previously,  no  union. 
Plate  was  removed  and  intramedullary  dowel  applied.  B,  six 
months  after  intramedullary  dowel  was  applied.    Perfect  result. 

"I  have  always  believed  that  the  less  non- 
absorbable foreign  material  used  the  better,  and 
my  next  preference  to  nothing  is  chromicized  gut; 


THE    USE    OF    FOREIGN    MATERIAL.  57 

and  I  prefer  a  single  screw  to  a  plate  and  eight 
screws"  (Williams).  Even  as  the  indications  for 
operation  vary,  so  do  those  for  the  internal  fix- 
ation. The  amount  of  internal  fixation  depends 
upon  whether  it  is  necessary  to  steady  the  frag- 
ments until  the  external  fixation  is  applied,  or 
whether  it  is  to  be  subjected  to  violent  strains,  as 
may  happen  for  instance  in  some  fractures  of  the 
femur.  It  has  been  amply  proven  by  experimental 
and  clinical  evidence  that  a  constant  strain  will 
loosen  the  strongest  form  of  internal  fixation;  just 
as  a  suture  drawn  too  tight  will  produce  absorp- 
tion and  cut  through  the  soft  parts,  so  will  a 
constant  strain  draw  or  loosen  the  screws  of  a 
plate,  no  matter  how  well  introduced.  The  point 
I  wish  to  make  is,  that  we  have  to  rely  chiefly 
upon  the  external  dressings,  the  function  of  the 
internal  fixation  being  to  obviate  positions  or  dis- 
placements which  may  be  caused  by  muscular 
action  or  by  sudden  strain,  such  as  ma)/-  happen 
during  the  application  or  change  of  external  splints 
or  dressings.  "One  of  the  chief  advantages  of 
internal  fixation  by  autogenous  bone-graft  is  the 
possible  earlv  and  passive  motion  of  neighboring 
joints    without    endangering   union"    (Blake). 

Therefore    all    foreign    material    should    be    con- 
demned,  and   their  use  be   discontinued. 


CHAPTER  IX. 

Technic  of  Transplanting  Boxe. 

In  order  to  be  successful  in  this  branch  of 
surgerv  one  must  have  a  very  complete  knowl- 
edge and  a  clear  conception  of  embryology,  his- 
tology, anatomy  of  the  bones  and  joints,  as  well 
as  the  form  or  type  of  regeneration,  not  only 
in  bone,  but  also  in  soft  tissues.  Xo  matter  how 
this  work  is  done,  or  what  theory  is  used,  it  must 
be  carried  out  along  definite  lines,  as  closely  as 
possible.  It  may  be  said  with  positiveness  that 
the  question  of  what  sort  of  material,  and  from 
what  source  it  should  be  taken,  in  the  osteoplastic 
work  has   been   solved. 

While  the  implantation  of  homogeneous  material 
derived  from  a  subject  of  the  same  species  may  be 
useful  in  a  limited  number  of  cases,  as  a  me- 
chanical support,  it  is  not  all  a  matter  of  repair- 
ing a  defect,  but  of  supplying  the  proper  means 
which  will  favor  the  reproduction  of  the  tissues 
to  fill  in  or  correct  the  defect.  This  is  a  well- 
known  fact  to  those  who  do  osteoplastic  work. 
We  cannot  repair  a  defect  in  bone,  but  we  can 
resort  to  procedures  which  will  stimulate  the  re- 
generation of  the  bone  already  present,  or  remain- 
ing, thereby  filling  in  the  defect  by  the  reproduc- 
tion of  tissue  (Fig.  18). 

All  fractures  should  be  treated  by  operative  in- 
terference  where  the   following   conditions   exist: 
(58) 


TECHNIC   OF   TRANSPLANTING   BONE.  59 

1.  Where  there  is  considerable  displacement  of 
fragments  that  cannot  be  otherwise  reduced,  or 
there  is  difficulty  of  maintaining  them  in  ap- 
position. 

2.  Where  reduction  cannot  be  completely  made 
by   manipulation. 

3.  Where  there  is  interposition  of  a  spicula  of 
loose  bone,   or   soft   tissue. 

4.  Where  fragments  are  rotated  upon  each 
other  and  cannot  be  reduced  and  held  in  position 
by  the   external  method. 

5.  Where  the  fracture  is  a  spiral  one;  also  in 
multiple    fractures,    etc.,    etc. 

Special  indications  are,  in  fractures  where  we 
have  pressure  upon  the  blood-vessels  or  nerves. 
Also  fracture  of  the  clavicle  if  the  patient  is  a 
lady,  and  wishes  to  appear  in  evening  gowns, 
perfect  apposition  is  necessary,  so  that  the  slight- 
est deformity  will  not  appear. 

In  fractures  of  the  upper  end  of  the  humerus, 
when  complicated  by  dislocation,  in  fracture  of  the 
shaft  of  the  humerus,  where  there  is  involvement 
of  the  musculo-spiral  nerve,  in  fracture  of  the  neck 
of  the  femur,  it  is  always  indicated,  and  in  the 
majority  of  cases  of  fractures  of  the  shaft  of  the 
femur,  as  it  is  difficult  in  most  cases  to  secure 
good  apposition  by  the  ordinary  method.  Statis- 
tics show  that  the  operative  treatment  has  been 
more  frequently  employed  in  connection  with  frac- 
tures of  the  leg  than  any  other  part  of  the  body. 

Fractures  in  close  apposition  to  the  joints,  as 
well   as    epiphyseal    separation,    with    displacements, 


60  MODERN*    OPERATIVE    BONE    SURGERY. 

demand  operative  interference.  Fragments  dis- 
placed in  the  elbow-joint  ( Fig".  19)  or  any  other 
joint,  are  apt  to  be  followed  by  serious  interfer- 
ence with  the  function  of  the  joint,  if  not  treated 
by   the    internal    fixation   method. 

Then  it  is  the  duty  of  the  surgeon,  knowing 
the  danger  menacing  the  patient  in  such  cases,  to 
proceed  at  once  by  operative  measures  to  correct 
such    conditions. 

The  operative  technic  for  articular  fractures  is 
very  difficult,  and  the  operation  should  not  be 
undertaken  by  a  surgeon  unless  he  has  had  con- 
siderable  experience    in   bone-work. 

The  advantages  of  an  open  reduction  in  simple 
fractures  are :  (  1  )  that  the  patient  is  able  to 
resume  his  occupation  at  an  earlier  date:  (2)  that 
the  large  blood-vessels  can  be  tied,  if  necessary; 
(3)  that  the  pressure  on  the  blood-vessels  and 
nerves  can  be  relieved :  ( 4 )  that  anatomical  accu- 
rate apposition  can  be  secured  and  maintained ; 
(5)  interposed  parts,  like  fragments  of  bone,  nerve, 
muscle,  and  periosteum,  can  be  removed :  (6)  in 
fractures  that  are  close  to  joints  there  is  less 
danger  of  ankylosis ;  ( 7 )  in  T-fractures  of  the 
elbow,  and  in  fractures  of  the  patella,  olecranon, 
and  os  calcis,  a  firmer  union  can  be  secured,  etc., 
etc. 

Hitzrot  has  well  said  that  "the  most  striking 
counterindications  for  operations  on  broken  bones 
are:  IXEXPERIEXCE  on  the  part  of  the  sur- 
geon, UNSUITABLE  SURROUNDINGS  and  IN- 
SUFFICIENT EQUIPMENT."     Furthermore,  the 


TECHXIC  OF  TRAXSPLAXTIXG  BOXE. 


61 


Pig-.  19.— Fracture  of  lower  portion  of  humerus  extending 
into  joint.  A  10-penny  finishing  nail  has  been  driven  through 
internal  condyle  and  lower  fragment  into  shaft  of  humerus. 
(/.  B.  Murphy.) 


62  MODERN    OPERATIVE   BONE    SURGERY. 

operator,  to  be  successful,  must  have  a  thorough 
knowledge  of  the  region  to  be  operated  upon,  and 
should  understand  the  action  and  function  of  the 
muscles,  ligaments,  etc.,  involved  in  the  injured 
member. 

Such  knowledge  may  prevent  some  of  the  most 
noticeable  failures  brought  about  in  the  treatment 
of  broken  bones. 

CAUTION  AGAINST  THE  TOO  ENTHUS- 
IASTIC ADOPTION  of  the  open  method  in  the 
treatment  of  fractures,  as  a  routine  means  of  deal- 
ing with  simple  fractures,  SHOULD  BE  GIVEN 
WITH  EMPHASIS. 

Excellent  results  can  often  be  secured,  both  as 
to  anatomical  restoration  and  function,  by  non- 
operative  treatment,  by  a  surgeon  of  experience, 
and  who  has  a  mechanical  mind,  and  who  has 
acquired  the  knowledge  of  the  management  of  the 
application  of  plaster-of-Paris,  and  the  use  of  the 
various  splints. 

There  is  no  question  in  the  author's  mind  but 
that  the  promiscuous  internal  use  of  the  Lane 
plate  has  done  much  to  prejudice  the  mind  of  the 
public  as  well  as  the  physicians  against  the  open 
treatment  of  fractures;  for  without  the  Lane 
technic,  which  few  possess,  the  application  of  a 
metallic  plate  or  any  foreign  body  to  or  within  the 
bone  invites  infection  and  delays  union  or  causes 
non-union.  Both  of  these  results,  especially  the 
latter,  and  to  a  very  large  degree  the  former, 
can  be  overcome  by  the  use  of  the  autogenous 
intramedullary  dowel,   or  the   inlay  bone  transplant. 


TECHNIC    OF   TRANSPLANTING   BONE.  63 

The  author  wishes  to  emphasize  again  that  the 
presence  of  the  metallic  plate,  instead  of  stimulating 
osteogenesis,  retards  it.  This  is  in  striking  contrast 
to  the  autogenous  bone-graft,  which  not  only  pro- 
duces bone  itself,  but  also  stimulates  the  bone  ends 
to  a  more  active  reparation.  If  properly  applied, 
an  immediate  adhesion  of  the  intramedullary  dowel 
or  inlay  to  the  walls  and  the  ends  of  the  fractured 
bone  occurs,  and,  as  time  elapses,  it  becomes  a 
firmer  and  firmer  bony  union.  Xot  only  does  the 
graft  have  the  above  qualities,  but  it  also  has  cer- 
tain  bacteria-resisting   and  bactericidal   properties. 

It  might  be  well  to  mention  again  a  few  of  the 
fractures  that  are  most  liable  to  require  the  open 
treatment;  namely,  the  long  bones,  especially  the 
femur;  fractures  involving  the  joints,  as  fractures 
of  the  neck  and  the  lower  end  of  the  femur;  the 
upper  end  of  the  humerus;  fractures  of  the  lower 
third  of  the   tibia,   and  fractures   of  the   forearm. 

Hitzrot  enumerated  the  following  indications 
for  open  treatment:  Fractures  of  the  head  of  the 
radius,  with  displacements  of  the  fragments,  or 
where  the  fracture  line  involves  the  radio-ulnar 
joints;  fracture  of  the  olecranon,  with  separation 
of  the  fragments;  fractures  of  the  head  of  the 
radius,  with  displacement;  fracture  of  the  patella, 
with  separation  of  the  fragments;  fracture  of  the 
shaft  of  the  long  bones,  in  which  the  soft  parts 
become  interposed  between  the  fractured  ends  of 
the  bone;  fractures  of  the  tarsal  and  carpal  bones, 
with  wide  separation  of  the  fragments,  or  dis- 
placements  of   the    fragments;    fracture   dislocation, 


64  MODERN'    OPERATIVE    BOXE    SURGERY. 

viz.,  fracture  of  the  neck  of  the  humerus,  with 
dislocation  of  the  head  of  the  humerus,  and  where 
the  tuberosities  and  condyles  of  the  various  bones 
are  fractured,  with  rotation  of  the  fractured 
processes;  for  example,  fracture  of  the  external 
condyle  of  the  humerus,  with  rotation  of  the  con- 
dyle, so  that  the  fractured  surface  points  outward. 
or   away   from   the   line   of   fracture   of   the    shaft. 

Especially  is  the  open  treatment  indicated  where 
we  have  hemorrhage,  due  to  injury  to  a  large 
vessel,  when  there  are  signs  of  compression  of  the 
nerves,  and  when  the  sharp  point  of  a  fragment 
is  caught  in  the  skin,  and  also  when  infection  has 
occurred   in  the   region  of   the   fracture. 

Most  every  type  of  fracture  needs  operative 
interference,  if  reduction  is  otherwise  unfeasible. 
The  necessity,  then,  for  open  treatment  should  be 
recognized    at   once. 

The  X-ray,  as  formerly  stated,  will  aid  ma- 
terially in  determining  this  fact,  by  looking  at  the 
fracture  from   several  different  angles. 

The  open  treatment  should  not  be  regarded  as 
a  method  only  to  be  employed  when  non-operative 
methods  have  failed,  as  the  results  of  secondary 
operations  compare  very  unfavorably  with  those 
of  immediate  operation.  As  previously  stated, 
skill,  perfect  technic,  and  surgical  judgment  are 
the  most  important  requisites  in  the  operative 
treatment  of  fractures,  as  a  considerable  propor- 
tion of  failures  is  due  to  infection  and  poor  judg- 
ment as  to  the  time  for  operative   interference. 

I   wish    to    emphasize    that,    in    order    to    secure 


TECHXIC   OF   TRANSPLANTING   BONE.  65 

the  most  satisfactory  results  from  the  open  treat- 
ment, it  should  be  resorted  to  as  soon  as  the  pa- 
tient can  be  placed  in  favorable  conditions  and 
surroundings,  and  not  defer  operative  procedures 
for  ten  days  or  two  weeks,  as  suggested  by  some 
authors. 

The  British  [Medical  Association  appointed  a 
committee,  February  19,  191 1,  "to  report  on  the 
ultimate  results  obtained  in  the  treatment  of 
simple  fractures,  with  and  without  operations". 

The   committee   reported   as   follows: 

"It  is  possible  by  either  non-operative  or  op- 
erative treatment  to  obtain  a  high  percentage  of 
good  results  in  children.  The  results  of  non-oper- 
ative treatment  in  children,  with  the  exception  of 
both  bones  of  the  forearm,  are  unlikely  to  be  im- 
proved upon  by  any  other  method.  Operative  re- 
sults expressed  in  percentage  are  approximately 
the  same  as  the  non-operative — 1017  non-operative 
cases,  90.5  per  cent,  good  functional  results;  64 
operative  cases,  93.6  per  cent,  good  functional 
results. 

"In  comparison  with  the  results  in  children, 
the  non-operative  results  in  those  past  15  are  not 
satisfactory;  and  from  the  analysis  of  the  age 
groups  it  is  clear  that  there  is  a  progressive  de- 
preciation of  the  functional  results  as  the  age 
advances  in  those  cases  submitted  to  non-operative 
treatment,  i.e.,  the  older  the  patient,  the  poorer  the 
result. 

"Although  the  functional  results  may  be  good, 
with  an  indifferent  anatomic  one,  the  most  certain 


66  MODERN    OPERATIVE   BONE   SURGERY. 

way  to  obtain  a  good  functional  result  is  to  se- 
cure a  good  anatomic  one.  The  operative  meth- 
ods which  secure  perfect  apposition  and  absolute 
fixation  of  the  fragments  yield  better  results  than 
methods  which  fall  short  of  this;  and  imperfect 
fixation  of  the  fragments  by  wire  or  other  suture 
has  been  found  unsatisfactory  in  fractures  of  the 
long  bones  (olecranon  excepted).  Operative  cases 
in  nearly  all  ages  show  a  higher  percentage  of 
good  results  than  non-operative  cases.  The  mor- 
tality due  to  the  operative  treatment  is  so  small 
that  it  cannot  be  urged  as  a  sufficient  reason  against 
this    method   of   treatment"    (Hitzrot). 

If  the  inlay  method  is  used  in  fresh  fractures, 
the  bone  being  normal,  the  material  for  inlay 
grafts  can  be  taken  from  the  fragments  them- 
selves, and  used,  as  a  stay  and  bridge  across  the 
fractured  ends  of  the  bone.  Here,  as  well  as  in 
other  similar  cases,  this  work  would  be  tedious 
and  unscientific  without  the  motor   saw. 


CHAPTER  X. 
Instruments  and  Their  Use. 

With  the  Geiger  motor  bone  instruments  one 
can  saw  bone,  drill  it,  turn  it  into  nails,  or  mould 
it  into  any  shape  or  form  required,  with  accuracy 
and  speed ;  so  that  the  surgeon  himself  can  develop, 
the  delicate  bone-work  that  is  necessary  in  any 
case,  with  the  least  possible  amount  of  time  and 
trauma. 

The  electric  saw  has  been  a  great  factor  in 
opening  up  the  field  of  osteoplasty,  and  the  appli- 
cation of  bone-graft  in  various  forms,  that  would 
have  been  almost  impossible  without  this  ingenious 
device.  Since  the  advent  of  the  motor  saw  it  would 
seem  barbarous  for  the  surgeon  to  attempt  to  re- 
move any  size  graft  from  one  part  of  the  living 
body  to  another  with  chisel  and  hammer.  All  cut- 
ting of  bone  that  was  formerly  laborious  is  now 
done  by  means  of  electric  power,  and  with  accuracy 
and  speed.  The  surgeon  can  do,  and  does,  many 
things  with  motor  instruments  which  would  be 
almost  impossible  with  hand  instruments. 

In  November  of  19 12  the  author  visited  New 
York,  and  while  in  one  of  the  large  clinics  wit- 
nessed the  removal  of  a  graft  from  the  tibia  eight 
inches  in  length,  which  was  placed  in  the  arm 
and  attached  to  the  epiphyseal  end  of  the  humerus 
at    the    shoulder-joint,    and   to   the    remaining   por- 

(67) 


68  MODERN    OPERATIVE   BONE   SURGERY. 

tion  of  the  shaft  of  the  humerus,  near  the  elbow- 
joint,  the  greater  part  of  the  shaft  of  the  hum- 
erus having  been  removed  five  years  previous,  on 
account  of  the  patient  having  osteosarcoma  of  the 
shaft  of  the  humerus.  It  took  the  surgeon  three 
hours  and  thirty  minutes  to  remove  the  graft 
from  the  tibia  of  the  patient,  and  place  it  in  posi- 
tion in  the  arm.  The  removal  of  the  graft  was 
accomplished  by  the  crude  method  of  hammer  and 
chisel.      This    unscientific    and    tedious    method    of 


Fig.  20.— Showing  reduction  gear  in  author's  motor,  which 
reduces  the  speed  from  7000  to  400  r.  p.  m.  The  cutters  only- 
run  400. 

removing  bone  grafts  so  impressed  the  author 
that  on  his  arrival  home  he  proceeded  at  once  to 
work  out  a  more  modern  idea  and  technic  of 
doing  bone-work.  The  author  conceived  the  idea 
of  devising  an  electric  motor,  with  reduced  speed, 
after  having  thoroughly  tried  out  the  high  speed 
motor,  and  found  it  not  practical,  as  it  burns  the 
bone  from  which  the  graft  is  removed,  and  also 
the  graft,  thereby  rendering  it  undesirable  for 
grafting  purposes. 


INSTRUMENTS    AND    THEIR   USE. 


69 


The  reduced  speed  idea  was  perfected,  and  the 
first  motor  that  was  completed  was  tried  out  by 
the  late  John  B.  Murphy,  November  13,  1913,  be- 
fore   the    Clinical    Congress    of    the    Sursreons    of 


Fig.  21. — Illustrating  position  in  which  the  late  John  B. 
Murphy  held  author's  motor  while  doing  bone-work. 

North  America,  at  Mercy  Hospital,  Chicago. 
After  a  thorough  test,  Dr.  Murphy  pronounced  it 
a  complete  success.  Dr.  Murphy,  who  aided  ma- 
terially   in    the    development    of    bone    surgery,    de- 


70  MODERN    OPERATIVE   BONE   SURGERY. 

voted  a  page  and  a  half  in  his  "Clinics"  to  this 
set  of  motor  instruments  in  the  February,  19 14, 
issue,  displaying  a  cut  of  the  motor  and  cutters 
that    were    developed   up    to    that    time. 


Fig.  22. — Skiagraph  showing  an  oblique  fracture  of  the  tibia 
and  fibula,  with  a  square  autogenous  intramedullary  dowel  in 
position.  When  correctly  applied  gives  perfect  fixation  and 
good  results. 

Considerable  improvement  has  been  made  on 
motor,  cutters,  and  accessories  since  Dr.  Murphy 
placed   his    signature    of    approval    thereon.      After 


INSTRUMENTS    AND    THEIR  USE.  71 

the  late  Dr.  Murphy  demonstrated  and  approved 
the  usefulness  of  the  motor-driven  instruments, 
November  13,  1913,  several  different  designs  of 
motor  devices  have  been  placed  on  the  market. 
The  work  that  is  now  being  done  in  bone  surgery 
is  quite  extensive,  i.e.,  dowel  and  inlay  grafts, 
tongued  and  grooved,  dove-tailed  mortises  and 
joints,  etc.,  which  could  not  be  successfully  done 
without   the   motor-driven    instruments. 

The  difficulty  in  early  days  in  getting  out 
bone-grafts,  and  the  results  following  the  open 
method,  then  accomplished  with  hand  instruments, 
caused  prejudice  and  scepticism  to  prevail,  and 
failure  to  recognize  the  real  value  of  the  trans- 
plant did  undoubtedly  delay  the  development  of 
this  most  valuable  surgical  agent  in  this  branch 
of  surgery.  The  main  reason  that  bone  surgery 
did  not  develop  along  with  the  surgery  of  the 
soft  parts  was  on  account  of  the  surgeon  being 
unable  to  procure  the  proper  instruments,  until 
within  the  last  four  years,  from  which  time  bone 
surgery  has   made    rapid   strides. 

In  surgery,  as  in  other  fields  of  work,  the 
general  use  of  electricity  for  lighting,  heating,  and 
power  purposes  in  hospitals  throughout  this  and 
other  countries  enables  the  surgeon  throughout 
the  civilized  world  to  procure  the  necessary  power 
for   operating  his   motor-driven   instruments. 


CHAPTER   XL 

Required  Efficiency  of  the  Motor. 

An  electro-operative  surgical  machine  for  do- 
ing bone-work  should  measure  up  to  the  following 
requirements : 

i.  The  speed  of  the  cutter  should  not  exceed 
that  of  400  revolutions  per  minute;  greater  speed 
renders    the    bone-graft    inert    by    burning    it,    and 


Fig.  23. — Right  angle  arm  used  in  deep  wounds  or  in  places 
which  cannot  be  reached  by  straight  arm.  To  this  all  cutters  or 
instruments  can  be  attached,  such  as  saws,  drills,  etc. 

thus   acting  as   a   foreign  body,   which   is   liable  to 
cause  suppuration. 

2.  Motor   should   be   sterilizable. 

3.  The  weight  of  the  motor  should  not  be  less 
than   four  pounds,   and   not  over  twelve  pounds. 

4.  The    motor    should   be    universal. 

5.  The  motor   should  develop  enough  power  to 
drive  all  cutters  or  instruments  used  in  bone-work. 

6.  The   switch   should  be  on   the   handle   of  the 
motor,    so    that    it    is    always    at    the    finger    ends, 

(72) 


REQUIRED   EFFICIENCY   OF   THE   MOTOR. 


73 


thus  permitting  easy  and  convenient  control  of  the 
electric   current. 

7.  The  chuck  should  be  simple,  so  that  all 
varieties  of  cutters  can  be  readily  adjusted.  The 
motor  should  be  so  constructed  as  to  give  perfect 


\ 

- 

\  i              * 

■fc   \V  y***^ 

Fig.  24. — Showing  T-wrench  in  position  in  motor  chnck, 
and  small  steel  bar  passing  through  handpiece  and  shaft  ready 
for  removal  of  chuck  to  be  sterilized. 

control  and  guidance  to  the  motor-driven  instru- 
ments, in  all  wounds,  and  at  all  angles  (Fig.  23). 
8.  All  cutting  instruments  should  be  con- 
structed similar  to  those  long  used  by  artists  for 
working    hard    materials,    and    should    be    of    sum- 


74 


MODERN    OPERATIVE    BOXE    SURGERY. 


cient  variety  to  meet  every  requirement  of  bone- 
work,  such  as  saws,  drills,  burrs,  twin  saws,  dowel 
cutters,   cranial   cutters,   trephines,   etc.,   etc. 


Fig.  25. — Illustrating  extra  guide  handle  in  position  on  steri- 
lizable  motor;  also,  showing  how  it  should  be  held  while  oper- 
ating parallel  saws.    Displays  sterilized  motor  without  shell. 

The    original    slow-speed    motor,    described    in 
this    chapter    was    devised    and    perfected    by    the 


Fig.  26. — The   author's   sterilizable   shell,  which   snugly   covers 
motor.    Used  when  one  does  not  wish  to  sterilize  the  motor. 

author,  and  fulfills  all  of  the  above  requirements. 
All  cutters  are  attached  directly  to  the  shaft 
which    passes    through    the    handpiece     (Fig.    24); 


REQUIRED   EFFICIENCY   OF   THE   MOTOR.  75 

the  handpiece  is  cast  integral  with  the  body  or 
housing  of  the  motor,  and  is  a  part  thereof.  This 
enables  the  surgeon  to  hold  the  cutter  firm  and 
rigid   while   operating    (Fig.    25). 

The  motor  is  sterilizable,  and  can  be  used 
without  the  shell;  however,  it  is  so  constructed 
that  a  shell  can  be  used  over  the  motor,  if  so 
desired  (Fig.  26).  In  a  CLEAN  case  it  is  not 
necessary  to  sterilize  the  motor,  as  the  shell  is 
sterilized,  which  covers  the  entire  motor,  and  the 
unsterilized  motor  cannot  come  in  contact  in  any 
way  with  the  part  being  operated  upon  or  with 
the  operator. 


CHAPTER  XII. 

Description  of  the  Author's  Motor  Instru- 
ments or   Cutters   and   Accessories. 

The  author's  electro-operative  bone  instruments 
consist  of  a  universal  motor,  i.e.,  one  that  will 
operate  without  adjustment,  on  either  direct  or 
alternating  current,  and  in  varying  cycles.  Stock 
motors  are  made  no  V.  60  Cycle;  higher  vol- 
tage  and   odd   cycle   are   made   special. 


|K22^ 


«e 


Fig.  27. — Electric  hot  air  sterilizer  with  thermostatic  control 
used  for  sterilizing  the  Geiger  motor. 

To  have  convenient  control  of  the  speed  of 
the  motor  it  is  quite  essential  to  have  the  hand- 
switch  at  thumb  or  finger  ends.  This  switch  is 
at  the  junction  of  the  handle  and  body  of  the 
motor,  and  by  a  motion  of  thumb  or  finger  the 
electric   current    is    turned   on   or    off. 

If  the  surgeon  desires  a  motor  with  different 
speeds,  this  is  obtained  by  using  a  foot  switch, 
especiallv  constructed  to  be  used  with  the  author's 
(76) 


AUTHOR'S    MOTOR   INSTRUMENTS. 


77 


motor,  and  which  gives  eight  different  speeds. 
The  foot  switch,  however,  has  its  disadvantages, 
for  should  the  surgeon  wish  to  move  from  one 
side  of  the  table  to  the  other,  or  change  his  posi- 
tion, he  must  move  the  switch  or  have  it  moved 
to   whatever   position   desired. 

The   motor   weighs    approximately   four   pounds, 
and  has  a  handle  and  handpiece  cast  integral  with 


Fig.  28. — Displaying  author's  unsterilized  motor  being  placed 
in  sterilized  shell.  Chuck  having  been  sterilized,  nothing  un- 
sterilized can  come  in  contact  with  operator  or  field  of  opera- 
tion.   Shell  is  held  firmly  together  \>y  thumb-nut. 

the  housing  of  the  motor  and  at  right  angles  with 
each  other;  both  are  cast  integral  with  the  body 
of  the  motor.  The  handpiece  permits  the  surgeon 
to  hold  the  cutters  perfectly  rigid  while  they  are 
in  operation. 

This    motor    will    stand    a    very    high    tempera- 
ture; the  temperature  used  for  sterilization  of  motor 


78 


MODERN    OPERATIVE    BONE    SURGERY. 


is    2500    F.,    which    insures    complete    sterilization 
within  thirty  minutes.     However,   should  the  oper- 


Fig.  29. — Shows  the  author's  motor  being  used  without 
sterilizable  shell. 


Fig.  30. — One  of  the  positions  in  which  the  motor  may  be 
held,  giving  firmness  to  motor  and  cutters.  Sterilizable  shell 
covers  motor. 

ator  prefer  to  use  the  sterilizable  shell  (Fig.  28),  it  is 
not  necessary  to  sterilize  the  motor,  only  after  oper- 
ating   on    pus    cases,    as    in    caries    and    necrosis, 


AUTHOR'S    MOTOR    INSTRUMENTS. 


79 


where  a  motor  burr  should  be  used  in  removing 
diseased  bone.  It  would  not  matter  in  a  case  of 
this  kind  whether  you  used  a  sterilizable  shell  to 
cover  the  motor  or  not,  as  it  could  not  fit  tightly 
enough  to  prevent  some  of  the  infected  material 
from  getting  within  the  sterilizable  shell.  The 
author  feels  much  more  secure  in  sterilizing  the 
entire   motor. 

The    sterilizable    shell    is    made    of    sheet    brass, 


Fig.  31. — Sterilized  chuck  being  attached  to  motor. 

nickel-plated.       It    is    quickly    adjusted    and    easily 
removed. 

The  chuck  (Fig.  31),  as  devised  by  the  author, 
is  very  simple  and  effective.  The  instrument  to 
be  used  by  the  operator  can  be  quickly  adjusted 
or  released  by  pulling  forward  the  ring  over  the 
spring  to  which  the  pin  is  attached,  thereby  forc- 
ing the  tapering  pin  down  through  the  shank  of 
the  instrument;  this  causes  the  cutter  to  be  firmly 
and    rigidly    fastened    within    the    chuck.       If    the 


80  MODERN    OPERATIVE   BOXE   SURGERY. 

operator  wishes  to  release  the  instrument,  he  can 
do  so  by  pulling  the  ring  back  over  the  spring, 
which  releases  it;  the  spring  raises  the  tapering 
pin  out  of  the  shank  of  the  instrument;  the  in- 
strument  can   now   be   removed   from   the   chuck. 

The  chuck  is  so  constructed  that  it  can  be 
easily  removed  from  the  shaft,  to  which  it  is 
attached  by  threads  or  grooves,  in  order  that  it 
may  be   sterilized   when   using  the   shell. 


CUTTERS    AXD    ACCESSORIES. 

The  author's  armamentarium  consists  of  an 
electric  motor,  electric-driven  instruments  and  ac- 
cessories used  in  bone  work,  which  are  as  follows : 

Drills.  Five  in  number;  sizes  ranging  from 
%4/r  to  Y%" '.  They  are  of  the  twist  drill  type, 
and  penetrate  bone  very  quickly,  with  great  ease 
and  with  little  friction,  and  do  not  burn  or  char 
the  bone. 

The  smaller  sized  drills — %-t"  and  %4" — are 
used  for  making  holes  in  transplants  and  recipient 
bone,  for  kangaroo  tendon,  to  hold  the  transplant 
in  position.  The  Y%"  drill  is  used  to  make  holes 
through  the  transplant  and  recipient  bone  for 
bone-pegs  to  hold  the  transplant  in  position.  The 
%e"  drill  is  used  to  make  holes  in  pieces  of  bone 
broken  away  from  the  main  bone,  such  as  con- 
dyles, protuberances,  etc.,  and  into  the  principal 
bone  to  receive  the  bone-pegs  to  hold  said  pieces 
of  bone,  condyles,  etc.,  in  position.  The  }i" 
drills   are   used   in   case   of   fracture   of   the   hip   to 


AUTHOR'S    MOTOR   INSTRUMENTS. 


81 


Fig.  32.— A  complete  set  of  the  author's  bone  instruments,  motor 
sterilizable  shell,  electric  sterilizer,  cutters,  and  accessories. 

6 


82 


MODERN    OPERATIVE    BOXE    SURGERY. 


bore  holes  through  the  greater  trochanter,  through 
the  neck,  and  part  way  through  head  of  the  femur, 
to  receive  the  autogenous  dowel  or  spike  so  as  to 
hold  the  fractured  neck  in  position. 

Saws.  The  single  saws  are  of  ten  assorted 
sizes,  ranging  from  Y\,f  to  2"  in  diameter, 
mounted    on    a    short    mandrel     or     shank,   which 


Fig.  33. — The  author's  latest  idea  of  motor  bone  saw.  The 
handpiece,  being  directly  behind  and  above  the  cutter,  gives 
the  operator  perfect  and  continuous  control  of  the  instrument 
while  it  is  in  operation. 

is  universal  in  size.  The  teeth  of  the  saws  are 
cross  cut,  and  of  different  sizes  and  sets;  being 
cross  cut,  they  cut  with  great  ease  in  living  or 
dead  bone.  The  set  of  the  saw  is  very  important, 
as  is  also  the  size  of  the  teeth ;  there  must  be 
enough  set  so  that  the  saw  will  not  "'bind'''  or 
produce  friction,  for  friction  will  produce  heat  in 
substance    that    is    as    hard    as    bone,    even    if    the 


AUTHOR'S    MOTOR   INSTRUMENTS.  83 

speed  of  the  saw  is  slow.  As  previously  stated, 
the  speed  of  the  author's  motor  will  not  exceed 
over  400  revolutions  per  minute  while  working, 
which  insures  against  overheating  of  the  bone,  if 
the  saw  has  the  proper  set.  However,  should 
there  be  friction  by  pinching  of  the  saw,  it  will 
create  heat,  which  may  greatly  interfere  with  the 
life  of  the  cells  of  the  bone  transplant;  or  if  the 
heat  is  great  enough,  it  would  burn  the  bone,  and 
render  it  unfit  for  the  desired  purpose.  The  use  of 
water  for  cooling  the  saw  washes  away  the  ma- 
terial   which    nature    has    so    wisely   provided,    viz., 


Fig.  34. — Extra  guide  handle  for  single  or  parallel  saws. 

blood  and  serum,  which  are  essential  for  the  im- 
mediate life  and  growth  of  the  transplant.  The 
single  saw  is  used  for  removing  bone-grafts  from 
any  location,  and  is  also  used  in  making  a  groove 
to    receive    the    inlay. 

Twin  or  Parallel  Saws.  Two  circular  saws  of 
the  same  size  placed  parallel  to  each  other  on  the 
same  shaft ;  the  distance  between  the  blades  varies 
from  %6"  to  ^2" ',  so  as  to  suit  the  location  or 
needs  of  the  case.  The  parallel  or  twin  saws  are 
used  in  removing  transplants  when  two  sides  are 
cut  parallel  to  each  other,  and  also  in  preparing 
the  recipient  bone  to  receive  transplants  shaped  in 
the   above   manner. 


84 


MODERN    OPERATIVE    EOXE    SURGERY 


Mandrel  or  shank,  for  single  or  twin  saws,  is 
short,  which  brings  the  saw  close  to  the  hand- 
piece.     The   part   of   the    shank   or   mandrel   which 


Fig.  35. — Two-inch  single  saw  with  saw-guard  for  regulating 
depth  of  saw,  in  position  on  mandrel,  ready  to  be  placed  in 
chuck  of  motor. 


Fig.  36. — Saw-guards,  eight  in  number,   for  regulating 
depth  of  saws. 

receives  the  saw  (as  shown  in  Fig.  33)  is  square, 
and  the  hole  in  the  center  of  the  saw  is  also 
square.  This  prevents  the  saw  from  turning  on 
said   shank.      The  nut  that  holds  the   saw   in  place 


AUTHOR'S    MOTOR   INSTRUMENTS. 


85 


on  the  mandrel  is  not  required  to  be  very  tight; 
it  can  be  brought  tight  enough  with  thumb  and 
finger;   a   wrench   is   not    required. 

Saw-guards  (as  shown  in  Fig.  36)  are  eight 
in  number,  and  the  sizes  range  from  y2"  to  ij4" 
in   diameter.      They   can   be   applied   to   either   twin 


Fig.  37. — Author's  sharp-nosed  burr  used  for  enlarging 
medullary  cavity,  removing  necrosed  bone,  etc. 

or   single   saws,   and  are  used   to   regulate  the   cut- 
ting   depth    of    the    saws. 

Reamers  or  Burrs.  These  are  two  in  number. 
No.  6  is  an  ordinary  cherry  burr,  with  3^" 
shank,  and  cutter  y§"  in  diameter.  No.  7  was 
specially  designed  by  the  author,  and  has  a  sharp 
nose  (Fig.  37).  This  burr  can  be  used  for 
making  holes  in  bone,  as  well  as  enlarging  medul- 


Fig.  38. — Author's  caliper  knives  used  in  measuring  and 
marking  or  laying  out  size  and  shape  of  grafts  to  be  removed, 
and  beds  or  cavities  in  which  they  are  to  be  placed. 


lary  canal  for  the  reception  of  the  dowel  or  re- 
moving dead  bone.  The  diameter  of  the  burr 
proper  is  y§" .  These  burrs  are  of  great  use  in 
the  preparation  of  tunnels  in  cancellous  bone  for 
the    insertion    of    dowel    or    peg    transplants. 


86  MODERN    OPERATIVE    EOXE    SURGERY. 

Caliper  knives,  No.  30  (Fig.  38)  is  a  very 
valuable  addition  to  a  set  of  bone  instruments,  as 
the  surgeon  lays  out  his  work  with  this  knife. 
If    the    surgeon    wishes    to    cut    a    graft    y2"    wide, 


Fig.  38/2. — Author's  periosteotome.  Anyone  doing  bone  surgery 
will  find  this  instrument  quite  convenient. 

he   sets  his   caliper  knives    l2   an  inch  apart,   draw- 
ing them  down  over  the  periosteal  covering  of  the 


Fig.  39. — Author's  tube-saw  or  dowel-shaper,  with  lathe 
attachment,  in  position  on  motor  ready  for  action. 


bone,  making  two  incisions  through  the  perios- 
teum, exactly  parallel  with  each  other,  and  the 
same  distance  apart  at  every  point.  In  cutting 
an    intramedullary    dowel    the    caliper    knife    is    in- 


AUTHOR'S    MOTOR   INSTRUMENTS. 


87 


dispensable;    for   you   caliper   the   medullary   cavity, 
and    cut    your    dowel    accordingly. 

Periosteotome  No.  38a  was  specially  designed 
by  the  author.  The  handle,  shank  and  all,  is  4" 
in  length;  the  cutting  part  is   Yz"  wide;  it  is  used 


Fig.  40. — Tube  saw  or  dowel  shaper  with  lathe  attachment 
in  position,  showing  vise  in  which  graft  is  placed  and  held 
firmly  while  bone-peg  is  being  made ;  the  hollow  bar,  which 
passes  over  handpiece  of  motor,  is  firmly  fastened  by  thumb- 
nut  to  handpiece. 

for  loosening  the  periosteotome  along  the  outer 
side  of  the  two  incisions  made  with  the  caliper 
knives. 

Dowel   shaper  s,    or    tube    sazvs    (Fig.    39),    are 


Fig.  41.— Author's  motor  trephine  showing  center  pin,  and 
guard  with  thumb-screw  which  govern  depth. 

three  in  number,  ranging  from  yi"  to  Y%" '.  The 
Ys"  dowel  shaper  is  used  in  making  pegs  or  nails 
to  hold  inlay  grafts  in  position.  The  %6/r  size 
is  used  for  making  dowels  for  pinning  the  broken 
condyles,  spicula  of  bone,  etc.,  in  position.  The 
large   size    (^j")    is   used   for   making  bone   spikes 


88  MODERN    OPERATIVE   BONE    SURGERY. 

or  dowels  to  be  used  in  fractures  of  the  neck  of 
the  femur.  The  tube  saw  can  be  used  with  or 
without  the  lathe  attachment  (Fig.  40).  How- 
ever,   it    is    much    easier    and    quicker    to    cut    a 


Fig.  42. — Author's  motor  protected  burr  or  cranial  cutter 
with  detachable  handpiece.  In  position  on  motor  ready  for 
action. 


dowel  with  the  addition  of  the  lathe  attachment  to 
dowel   shapers. 

The  three  different  sized  dowels  made  by  the 
three  different  size  tube  saws  fit  snugly  in  the 
holes  made  by  the  y%" ',  z/\§" ,  and  Y%"  drills. 
Should  an  attempt  be  made  to  use  the  dowel  cut- 


AUTHOR'S    MOTOR   INSTRUMENTS.  89 

ters  or  tube  saws  without  the  lathe  attachment, 
it  is  necessary  to  have  two  assistants  to  hold  the 
bone-graft   firmly,    and   push   it    gradually   into   the 

tube    saw. 

Trephine    No.    22    (Fig.    41 )    was    designed   by 


Fig.  43 —Author's  protected  burr  or  skull  cutter. 


Fig  44 -Authors  bone-graft  retaining  forceps  with  project- 
in-  jaws,  for  the  purpose  of  passing  down  into  saw-furrow  to 
remove  graft  from  its  original  bed.  Also  shows  ratchet  on 
forceps  which  locks  jaws  and  holds  graft  firmly  while  being 
placed  between  the  fractured  ends  of  bone. 

the  author,  and  is  the  most  ingenious  and  valu- 
able instrument  in  the  set.  It  has  a  thumb-nut 
by  which  you  regulate  the  cutting  depth;  and  by 
feeling  your  way  you  can  absolutely  prevent  in- 
jury to  the  dura.     It  cuts  a  hole  /2"  in  diameter, 


90 


MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  45. — The  author's  twin  saws  with  extra  guide  handle,  in 
position  on  motor  ready  for  operation. 

giving   ample   room   through    which   to   inspect   the 
dura   or   introduce   the    skull   cutter. 

Protected    burr    or   skull    cutter,    No.    33    (Fig. 
42),  in    position    ready    for    action    as    planned    by 


Fig.  46. — Author's   right-angle  arm  in  position  on   sterilized 
motor,  with  single  saw  attached  ready  for  operation. 


AUTHOR'S   MOTOR   INSTRUMENTS. 


91 


the  author,  has  a  shoe  or  protector  which  dis- 
sects the  dura  from  the  skull,  and  also  prevents 
the  burr  from  injuring  the  soft  parts.  The  burr 
is  %"  in  diameter.  The  part  of  frame  which 
forms  the  shoe  is  so  constructed  that  the  detach- 
able handpiece  (Fig.  43)  is  fastened  thereon 
and  enables  the  operator  to  give  great  force  to 
the  cutter  or  burr,  and  also  to  have  absolute  con- 
trol  of   the   instrument   at   all   times. 

Bone-graft  retaining  forceps.  No.  38  (Fig.  44), 
as  designed  by  the  author,  is  a  very  important 
instrument    to    anyone    that    is    doing    plastic    bone 


Fig.  47. — The  author's  bone-elevating  forceps. 


surgery.  It  is  used  in  removing  the  graft  from 
its  bed,  and  placing  it  in  position.  The  nose  of 
the  forceps  is  Y^'  wide,  which  projects,  as  shown 
in  the  above  cut,  which  makes  it  easy  to  remove 
a  graft  from  its  bed.  The  forceps  is  also  supplied 
with  a  ratchet,  which  holds  the  jaws  firmly  in 
position  wherever  placed,  and  prevents  the  graft 
from  getting  loose  from  the  forceps,  which  is  of 
great  .importance.  Many  a  graft  has  been  ren- 
dered unfit  for  use  by  being  dropped  accidentally 
on  the  floor  while  using  the  ordinary  forceps. 
After  the  graft  is  once  in  the  jaws  of  this  forceps 
it  cannot  get  away  unless   released. 


92 


MODERN    OPERATIVE   BONE    SURGERY, 


Bone-elevating  forceps,  No.  37  (Fig.  47),  was 
devised  by  the  author,  and  is  used  for  lifting  the 
ends  of  the  fractured  bones  into  position,  or  hold- 


Fig.  48. — Author's  bone  skids  or  elevating  spoons,  used  in 
breaking  up  adhesions  in  ununited  fractures,  and  to  serve  as  a 
pry  in  adjusting  fractured  ends  of  bone. 

ing  ends  firmly  while  they  are  being  prepared  to 
receive  the  graft  or  inlay,  or  intramedullary  dowel. 
Bone-elevating  spoons  or  skids,  Nos.  35  and 
36  (Fig.  48),  are  two  in  number:  one  straight 
and    the    other    curved.      They    are    specially 


con- 


Fig.  49. — Author's  bone-clamp,  which  is  indispensable  in 
getting  out  sliding  inlay  grafts.  The  clamp  is  applied ;  the  ends 
of  the  bone  are  brought  into  apposition  and  held  firmly  by  the 
clamp,  while  sliding  graft  is  removed  from  one  fragment  or  the 
other  with  twin  or  single  saws  and  placed  in  position.  The 
clamp  does  not  interfere  with  the  removal  or  with  the  placing 
of  the  graft  in  position,  being  open  on  upper  surface,  as  illus- 
trated. 


AUTHOR'S    MOTOR   INSTRUMENTS.  93 

structed  by  the  author,  and  are  used  for  breaking 
up  fibrous  adhesions  between  the  ends  of  un- 
united fractures,  and  prying  or  elevating  ends  of 
fractured    bones    into    position. 

Fracture  clamp  (Fig.  49),  is  used  to  hold  the 
fractured  ends  of  the  bone  in  position,  while  the 
inlay  graft  is  cut  from  above  or  below  the  frac- 
ture. The  Geiger  clamp  is  so  constructed  as  to 
enable  the  surgeon  to  cut  inlay  graft,  remove  the 
graft  from  its  original  bed,  and  put  it  in  its  new 
position,  while  the  clamp  is  applied,  and  holds  the 
fractured  ends  of  the  bones  in  perfect  anatomical 
relation. 


CHAPTER  XIII. 

Orthopedic  and  Fracture  Extension  Device. 

In  all  fractures  of  the  extremities  it  is  essen- 
tial that  perfect  and  continuous  extension  be  made 
upon  the  injured  limb  while  the  dressing  is  being 
applied.      This    cannot   be    successfully   done   unless 


Fig.  50. — Author's  extension  device  attached  to  operating 
table  with  shoulder-  and  head-  support;  saddle  raised,  extension- 
arms  raised,  ready  for  application  of  bandages  or  dressing  to 
hip  or  lower  portion  of  body. 

the  surgeon  has  at  his  disposal  a  device  made  for 
such   purpose. 

The    Charles    Geiger    orthopedic    and    fracture 

extension   apparatus   fills    all   the   requirements.      It 

can  be  fastened  to  any  operating  table    (Fig.   50), 

which   is   accomplished   by   means   of  three   clamps. 

(94) 


ORTHOPEDIC   AND    FRACTURE   EXTENSION. 


95 


This  extension  obviates  the  necessity  of  having  a 
special  table  made  for  such  purpose,  as  it  can  be 
applied  to  any  operating  table  in  a  moment's  time 
when  desired,  and  can  be  removed  quickly  when 
no  longer  needed,  and  placed  in  a  corner  out  of 
the  way  until  it  is  again  required,  which  makes  it 
most  valuable. 

When  knocked  down  it  is  so  constructed  that 
it  occupies  only  a  small  space,  the  longest  part 
being  but  three  feet  in  length.  Should  the  operator 
desire  to  use  it  at  some  other  hospital  or  hospitals,  it 


Fig.  51. — Author's  extension  device  knocked  down,   ready 
to  be  placed  in  carrying  case. 


can  be  placed  in  a  carrying  case  (Fig.  51), 
specially  constructed  for  such  purpose.  Not  only 
is  this  device  easily  portable,  but  you  can  do  any- 
thing with  it  that  can  be  done  with  any  fracture 
or  orthopedic  table;  it  fills  every  requirement 
called    for    in    orthopedic    or    fracture    work. 

If  extension  of  the  arm  is  necessary,  as  in 
fracture  of  the  neck  of  the  humerus,  or  any  other 
part  of  the  arm,  perfect  extension  and  counter- 
extension  can  be  made  with  this  device   (as  shown 


96 


MODERN    OPERATIVE   BONE    SURGERY. 


Fig.  52. — Author"s  extension  device  with  hand  in  position  on 
handpiece  and  arm-rest;  also,  counterextension  produced  by- 
piece  of  plate  steel  four  inches  wide,  shaped  to  chest. 


Fig.  53. — Author's  orthopedic  and  fracture  extension  device, 
with  subject's  legs  in  extreme  abduction  (Whitman's  position), 
for  treatment  of  fractures  of  the  neck  of  the  femur.  Display- 
ing the  perfect  saddle,  which  is  so  constructed  that  it  absolutely 
prevents  any  pressure  upon  the  urethra.  Also  shows  leg  sup- 
port just  above  the  knee. 


ORTHOPEDIC   AND    FRACTURE    EXTENSION. 


97 


in  Fig.  52).  The  counterextension  is  accom- 
plished by  a  piece  of  steel  plate,  4"  wide  and  12" 
long,  shaped  to  the  chest.  When  traction  is  made 
on  the  arm,  the  counterextension  brought  about 
by  this  device  does  not  interfere  with  the  move- 
ments of  the  chest  in  breathing.  This  is  very 
important,     as     in     the    breathing    of     all     persons 


Fig.  54. — Side-view  of  author's  orthopedic  and  fracture  ex- 
tension device,  with  saddle,  and  shoulder-  and  head-  supports  in 
position,  ready  for  applying  dressings  to  hip  or  back. 


under  anesthetic,  while  major  work  is  being  done, 
the  motion  of  the  chest  should  not  be  hampered. 
The  broad  band  of  cloth  used  in  other  devices 
is  extremely  dangerous,  as  it  seriously  impairs 
breathing",  and  endangers  the  life  of  the  patient 
under  such  conditions ;  it  should  be  condemned. 
The    Whitman   position    for    treatment    of    frac- 


98 


MODERN    OPERATIVE   BONE    SURGERY. 


tures  of  the  neck  of  the  femur — extreme  abduc- 
tion— is  easily  accomplished  with  this  device  (Fig. 
53).  The  rotation  of  the  femur  is  controlled  by 
the  footpiece  or  plate.  Fig.  53  also  shows  the 
saddle     used     which     protects     the     perineum,     and 


Fig.  55. — Displaying  footpiece  of  author's  extension   device. 
Foot  fastened  in  position,  ready  for  extension  of  limb. 


especially  the  urethra,  from  undue  pressure  or 
trauma.  The  saddle  gives  perfect  counterexten- 
sion,  and  with  head-  and  shoulder-  supports  (Fig. 
56)  elevates  the  body  and  hips,  so  that  plaster- 
of-Paris'  dressing  or  other  dressings  can  be  ap- 
plied  to    the   lower   portion    of    the    trunk    or    hips 


ORTHOPEDIC   AND   FRACTURE   EXTENSION. 


99 


without  any  interference  to  the  operator.  Trac- 
tion can  be  applied  to  a  limb  in  any  degree 
of  abduction,   which   is   frequently  of   great   advan- 


Fig.  56. — Demonstrating  the  application  of  spica  bandage  to 
hip.  Showing  clearance  under  body,  with  pelvis  resting  by 
saddle,  and  the  upper  portion  of  body  resting  on  head-  and 
shoulder-  supports. 

tage,  especially  in  fractures  of  the  upper  third  of 
the  femur.  As  in  all  other  fractures,  the  neutral 
position  should  be  made  the  most  of.  In  other 
words,    the    displacing    forces    should    be    overcome 


100 


MODERN    OPERATIVE   BONE   SURGERY. 


by  placing  the  limb  in  such  position  as  to  bring 
about  the  desired  results.  Reduction  should  be 
completely  accomplished.  If  unable  to  do  so  by 
external  manipulation,  the  open  method  should  be 
resorted  to,  and  the  bones  placed  in  perfect  ap- 
position and  the  limb  in  a  neutral  position, 
after  which  a  plaster-of-Paris  dressing  should  be 
applied    without    the    position    of    the    limb    being 


Fig.  57. — Author's  extension  device,  with  head-  and  shoul- 
der- rests  in  position;  extension-arms  at  right  angle  with  table, 
ready  for  extension  of  patient's  arm. 


changed  or  the  traction  being  released  the  slight- 
est. This  dictum  applies  in  all  cases  in  reduction 
of  fractures,  whether  operative  or  non-operative 
methods  are  employed,  and  irrespective  of  the 
type  of  internal  fixation,  if  such  is  to  be  used. 
No  internal  fixation  method — viz.,  steel  plate,  bone 
inlay,  intramedullary  dowel,  etc. — will  for  any 
length  of  time  stand  the  pulling  of  strong  muscles 
at   cross-angles    to   the    fractured   part.      Kangaroo 


ORTHOPEDIC   AND    FRACTURE   EXTEXSIOX.         101 

tendon  will  break,  wire  will  cut  through  bone, 
screws  will  pull  out,  bone  transplant  will  necrose 
and  break,  if  continuous  pressure  is  applied  thereto. 

In  fastening  the  feet  or  hands  to  the  foot-  or 
hand-  piece  of  the  author's  extension  device,  a 
retaining  bandage  of  double  ducking  21o'/  inches  wide 
and  3  yards  long,  is  used  (Fig.  55),  in  the  center 
of  which  has  been  sewed  a  piece  of  Mexican 
felt,  3"  wide  and  15"  long;  this  acts  as  a  pro- 
tection-cuff for  the  ankle  or  wrist.  Across  this 
bandage,  1^2"  to  the  right  and  l1/^'  to  the  left 
of  the  center,  are  sewed  two  straps;  one  about 
10"  long,  having  holes  in  it  an  inch  apart,  and 
the  other  about  3"  to  ^/z"  long,  having  a  buckle 
on  the  end.  When  the  bandage  is  in  position 
these  straps  run  parallel  with  leg,  and  are  passed 
around  the  footpiece,  drawn  tight,  and  buckled; 
this  holds  foot  firmly  in  position.  In  placing  the 
bandage  to  the  foot,  the  middle  of  it  is  firmly 
applied  over  the  tendo  Achillis;  the  right  end  is 
brought  up  on  the  right  side  of  the  foot,  and  the 
left  end  on  the  left,  and  so  on,  until  the  foot  is 
firmly  fastened.  You  are  now  ready  to  make  your 
extension   by   turning   the    hand-nut    of   the   device. 

In  applying  plaster-of-Paris  bandage  to  leg  or 
arm,  while  extension  is  being  made  with  the 
author's  extension  device,  the  cast  is  extended 
down  to  ankle  or  wrist,  and  is  allowed  to  par- 
tially dry;  then  the  extension  is  released,  and 
retaining  bandage  is  removed,  after  which  the 
wrist  and  hand  or  ankle  and  foot  are  covered 
with   a  plaster  bandage. 


102 


MODERN    OPERATIVE    BONE   SURGERY. 


Geiger-Murphy  Orthopedic  and  Fracture  Ex- 
tension Table.  The  outfit  consists  of  a  modified 
Murphy  hydraulic  operating  table  in  conjunction 
with  the  Geiger  orthopedic  and  fracture  extension 
device.  This  device  comes  complete  with  all 
necessary  attachments  for  orthopedic  and  fracture 
work.      Plaster   casts   or    dressings    can   be   applied 


Fig.  57a. — Exhibits  extension  arms  of  the  Geiger-Murphy 
fracture  and  extension  table,  in  position  with  saddle,  which  fits 
the  perineal  region  perfectly,  and  gives  perfect  counter-exten- 
sion, used  in  extending  the  lower  limbs  in  reduction  of  fractures 
in  the  open  or  closed  method ;  also  for  the  application  of  inter- 
nal splints  (bone-grafts)  and  the  application  of  plaster-of-Paris 
and  other  dressings  to  the  limbs,  hips  and  body. 

to    hip,    back,    or    any    part    of    the    body    or    limb 
without   obstruction   and   with   ample   clearance. 

A  particularly  noteworthy  fact  is  that  the 
operating  table  is  not  in  the  way  when  applying 
dressings  to  the  extremities.  Perfect  and  contin- 
uous extensions  can  be  secured  on  the  smallest 
child   as   well   as   the   largest   man.      The   extension 


ORTHOPEDIC   AND    FRACTURE   EXTENSION.         103 

arms  are  fitted  with  attachments  for  either  hand 
or  foot,  with  rests  for  arms  and  legs,  and  may 
be  used  at  any  angle  from  180  degrees  to  prac- 
tically a  parallel  position.  Extension  is  secured 
by  a  steel  screw  on  each  of  the  extension  arms. 
All  attachments  are  heavily  and  well  constructed. 


Fig.  57b. — Displaying  Geiger-Murphy  fracture  and  extension 
table,  with  head-  and  shoulder-rest  and  extension  arms  in  posi- 
tion. Extension  arms  at  right  angle  with  table  for  the  extension 
of  arms  for  the  reduction  of  fractures  by  the  closed  method,  or 
for  the  open  method  of  reducing  fractures,  the  application  of 
internal  splints  (bone-grafts),  or  surgical  dressings,  such  as 
plaster  casts,  etc. 


CHAPTER  XIV. 

General   Remarks   on   Technic. 

The  general  preparation  required  for  bone 
surgery  does  not  differ  from  that  demanded  by 
any  other  major  surgical  procedure.  The  local 
preliminary  preparations  are  made  the  day  pre- 
vious  to  the   operation. 

The  limb  or  field  to  be  operated  upon  is  pre- 
pared as  follows :  The  skin  is  scrubbed  with 
soap  and  boiled  water,  shaved,  and  washed  with 
alcohol.  After  thoroughly  drying  the  part,  a 
half  strength  of  the  common  tincture  of  iodine 
is  applied  to  the  field,  and  then  it  is  covered  with 
a  sterile  gauze,  which  is  fastened  to  the  part  by 
adhesive  plaster.  At  the  time  of  the  operation 
the  skin  is  mopped  thoroughly  with  tr.  iodine 
half  strength,  then  apply  alcohol  freely,  remov- 
ing the  tincture  as  completely  as  possible.  The 
use  of  antiseptics,  excepting  the  iodine,  on  the 
day  of  operation  is  absolutely  useless;  in  fact 
they  are  harmful,  for  anything  that  is  strong 
enough  to  destroy  pyogenic  germs  will  also  de- 
stroy the  living  bone-cells,  if  perchance  it  should 
come  in  contact  with  the  same.  Anything  that  in- 
hibits or  kills  the  growth  of  the  living  cells,  such 
as  bichloride  of  mercury,  carbolic  acid,  or  any 
chemical  of  such  nature,  should  not  be  used  in 
the  preparation  of  the  operative  field  at,  or  just 
prior  to,  the  time  of  operation. 
(104) 


GENERAL   REMARKS    ON    TECHNIC.  105 

If  the  above  antiseptics  are  used  on  the  day 
or  at  the  time  of  operation,  they  should  be  re- 
moved as  completely  as  possible  by  washing  with 
alcohol,  for  if  they  are  allowed  to  remain  and 
come  in  contact  with  any  part  of  the  bone  or 
graft  they  will  destroy  the  cells  of  such  part, 
inhibit  growth,  and  invite  infection.  It  is  quite 
evident  that  a  special  technic  is  required  in  bone 
surgery.  Rigid  operative  asepsis  must  be  main- 
tained; the  application  of  the  rubber  gloves  to  the 
surgeon's  hands  must  be  under  the  most  rigid 
technic,  viz.,  the  gloves  must  be  thoroughly  steril- 
ized, then  dried,  after  which  the  gauntlet  of  the 
glove  must  be  turned  back.  The  nurse,  with 
gloved  hands,  now  slips  her  fingers  between  the 
reversed  gauntlet  on  either  side  of  the  glove,  and 
produces  traction,  which  permits  the  surgeon  to 
introduce  his  hand  well  into  the  glove.  The  outer 
or  external  surface  of  the  gloves  must  not  be 
touched  or  come  in  contact  with  the  ungloved 
hands  of  the  surgeon  or  of  anyone  else,  or  with 
the  prepared  or  unprepared  skin  of  the  part  to  be 
operated  upon,  as  it  is  impossible  to  sterilize  the 
skin  under   such   conditions. 

After  a  free  incision  has  been  made,  the  skin 
is  pulled  back.  Sterile  towels  are  now  fastened  in 
the  wound,  between  the  surface  of  the  incised 
skin,  so  that  the  instruments  or  gloved  hands  of 
the  operator  cannot  come  in  contact  with  any  part 
of    the    skin. 

To  emphasize,  a  special  technic  is  required  in 
bone    surgery.      Rigid    operative    asepsis    must    be 


106  MODERN    OPERATIVE   BONE   SURGERY. 

maintained.  Great  care  must  be  taken  not  to 
wound  or  lacerate  the  tissues  any  more  than  is 
absolutely  necessary.  The  vitality  of  the  trans- 
plant depends  largely  upon  the  care  in  removing 
it,  and  retaining  it  in  as  nearly  a  normal  condi- 
tion as  possible.  The  native  blood  and  the  serum 
should  be  kept  on  the  surface,  and  within  the 
graft.  Consequently  the  change  from  the  old  to 
the  new  location,  or  bed,  must  be  made  quickly, 
so  that  nature's  life  fluid  will  be  conserved  and 
not  desiccate  or  drain  away,  should  there  be  a 
temporary  delay  between  the  removal  of  the  trans- 
plant and  the  placing  of  it  in  its  new  bed.  It 
must  not  be  placed,  or  an  attempt  be  made  to 
preserve  it,  in  saline  or  other  solutions,  because 
they  remove  that  which  should  be  retained — the 
fluids  of  life  (blood  and  serum),  which  sustain 
the  vitality   of  the   transplant. 

In  case  of  delay,  the  graft  should  be  wrapped 
in  sterile  oil  silk  to  exclude  the  air  and  retain  the 
moisture.  Water  should  never  be  applied  to  a 
wound  in  order  to  keep  the  motor  saw  or  other 
cutters  from  burning  the  bone,  or  for  cleansing 
purposes,  for  it  invites  infection,  and  removes  the 
vital  substance  you  wish,  to  retain,  and  in  fact 
always    does    more   harm    than   good. 

In  controlling  hemorrhage  in  plastic  bone  work, 
the  tourniquet  is  counterindicated,  because  of  the 
danger  of  reactionary  hemorrhage  with  clots  in 
the  deep  part  of  the  wound,  which  would  inter- 
fere with  the  vascularization  of  the  transplant. 
To    control    the    hemorrhage    from    small    vessels 


GENERAL   REMARKS    ON    TECHNIC.  107 

and  capillaries  of  the  soft  parts,  the  wound 
is  packed  with  gauze  thoroughly  wrung  out 
of  hot  normal  salt  solution.  Arteries  and  veins  of 
any  size  are  picked  up  with  hsemostats,  and  tied 
with  absorbable  ligatures.  Great  care  must  be  ex- 
ercised in  seeing  that  all  bleeding  is  controlled; 
many  operations  have  failed  to  give  the  desired 
results  because  of  the  lack  of  the  proper  attention 
given  to  the  complete  stopping  of  hemorrhage 
in  the  bone,  as  well  as  in  the  soft  parts. 
Then  with  complete  hemostasis  and  the  transplant 
in  position,  the  wound  is  closed  without  drainage, 
in  layers  with  absorbable  sutures,  and  covered 
with  an  abundance  of  sterile  gauze,  sufficient  to 
give  proper  protection  to  the  wound  without  fur- 
ther interference  for  six  to  eight  weeks,  or  until 
we  have  bony  union. 

The  real  success  of  the  transplant  depends 
largely  on  the  actual  contact  between  the  osteo- 
genetic  surface  of  the  host  and  the  osteogenetic 
surface  of  the  transplant.  Periosteum,  fat,  fibrous 
tissue,  muscle,  or  blood-clots  of  any  considerable 
size  prevent  the  graft  from  uniting  to  the  host,  to 
the  extent  of  their  interposition.  Too  much  can- 
not be  said  in  regard  to  the  injury  of  the  super- 
ficial cells  of  the  bone-graft,  or  the  contacting  sur- 
face of  the  host.  As  previously  stated,  great  cau- 
tion should  be  exerted  in  preventing  frictional 
overheating  of  the  sawed  surface  by  the  speed  of 
the  electric  saw,  also  from  contacting  the  graft 
to  its  host  so  tightly  as  to  produce  superficial 
pressure  necrosis. 


108  MODERN    OPERATIVE   BOXE   SURGERY. 

I  again  wish  to  emphasize  the  importance  of 
bearing  in  mind  that  the  antiseptics  sometimes 
used,  if  brought  in  contact  with  the  superficial 
cells1  of  the  bone-graft  or  its  host,  may  do  irrep- 
arable injury  by  destroying  the  cells  of  such  sur- 
face; that  by  the  time  the  injured  cells  have  died, 
become  absorbed  and  cleansed  away,  the  underly- 
ing layer  of  living  bone  of  the  host  and  the  graft 
will  have  healed  over,  and  will  fail  to  unite  or  to 
graft  over   such   surface. 

An  ideal  transplant  contains  periosteum,  cor-^ 
tical  bone,  endosteum  and  marrow.  If  used  as 
an  inlay,  the  corresponding  layers  of  the  host 
should  come  in  contact  with  the  same  lavers  of 
the  transplant.  The  inlay  graft  should  be  taken 
from  as  near  the  location  of  the  fracture  as  pos- 
sible (Fig.  j$,  Geiger  method);  for  a  transplant 
having  the  same  consistency  as  the  host  has 
proved  superior  to  one  removed  from  remote  or 
distant  parts  of  the  body. 


CHAPTER  XV. 

Elements  Essential  in  a  Transplant  for 
Continued  Success. 

THE  ESSENTIAL  ELEMENT  OF  A  TRANS- 
PLANT IS  CORTICAL  BONE,  BECAUSE  OF 
ITS  RESISTANCE  TO  CHANGE  OF  FORM, 
BY  WHICH  IT  GIVES  SUPPORT  TO  ITS 
HOST;  ITS  SMALL  VASCULAR  SUPPLY, 
WHICH  ALLOWS  IT  TO  RETAIN  ITS  VI- 
TALITY FOR  A  CONSIDERABLE  LENGTH 
OF  TIME  AFTER  TRANSPLANTATION;  ITS 
CAPABILITIES  OF  BEING  SUSTAINED  BY 
A  SMALL  AMOUNT  OF  NUTRITION;  AND 
ITS  ACTIVE  OSTEOGENETIC  PROPERTIES 
CAUSE  IT  TO  GRAFT  WITH  RAPIDITY 
AND  FIRMNESS.  The  early  vascularization  of 
the  transplant  is  materially  aided  by  the  perios- 
teum and  endosteum.  It  has  been  repeatedly 
demonstrated  and  proved  to  be  a  fact  that  small 
fragments  of  bone  retain  their  vitality  and  graft 
better  and  quicker  than  larger  fragments.  So 
the  transplant  should  be  composed  of  the  smallest 
amount  of  bone  that  will  fulfill  all  the  re- 
quirements. 

In  intramedullary  dowel,  bone-peg,  or  spike, 
the  periosteum  must  be  removed  from  the  parts 
that  have  bone  contact,  and  which  extend  up  into 
the    fractured    ends    of    the    recipient   bone.     If  the 

(109) 


HO  MODERN   OPERATIVE   BONE   SURGERY. 

ends  of  the  fractured  bone  come  together,  the 
dowel  should  be  without  periosteum.  If  consider- 
able space  exists  between  the  ends  of  the  bone, 
that  part  of  the  transplant  not  covered  by  the  re- 
cipient bone  should  possess  all  of  the  periosteum 
possible.  This  demonstrates  the  reason  why  the 
fibula  makes  such  an  excellent  transplant.  The 
proper  fitting  of  the  transplant  to  the  host  often 
furnishes    fairly   good   fixation. 

It  may  be  necessary  at  times,  however,  to  re- 
inforce the  fixation  by  bone-pegs  or  by  the  use 
of  kangaroo  tendon  sutures  passed  around  the 
transplant,  and  through  the  holes  drilled  in  the 
host  and  graft.  Wire  nails  or  any  metallic  sub- 
stances should  never  be  used  as  fixation  of  trans- 
plants to  hosts,  as  this  fixation  can  be  accom- 
plished with  autogenous  bone-pegs.  Before  com- 
pleting the  fixation  of  the  bone-graft  it  is  quite 
essential  to  neutralize  the  muscular  action  by 
position,  and  to  neglect  this  will  allow  a  spasmodic 
movement  between  the  transplant  and  the  host. 
The  position  of  the  limb  or  part  operated  upon 
should  be  a  position  of  normal  alignment  and  ro- 
tation, in  which  there  is  complete  relaxation  of 
the   muscles   acting  upon   the   area   of   autoplasty. 

Should  the  above  not  be  carried  out  in  detail, 
irregular  movements  or  leverages  will  either  dis- 
lodge the  transplant,  shear  it  across,  or  cause  it 
to  cut  through  its  bed  or  host,  the  course  depend- 
ing upon  the  direction  furnishing  the  least  re- 
sistance. 

To   immobilize  the  limb,   a   close-fitting  plaster- 


FOR  A   SUCCESSFUL   TRANSPLANT. 


Ill 


of-Paris  cast  cannot  be  excelled.     The  cast  is   ap- 
plied  including  one   or  more   joints   above   and  be- 


Fig.  58. — A,  Geiger  motor  plaster-of-Paris  cutter;  B,  plas- 
ter-of-Paris  cutter  in  operation.  Note  the  firmness  with  which 
the  machine  can  be  held. 

low   the   autoplastic  work  or   repair.     The  fixation 
must    be     complete    and    continuous,    until     staple 


112  MODERX    OPERATIVE   BOXE   SURGERY. 

grafting  or  bony  union  has  occurred  between  the 
inlay  and   the   recipient  bone. 

It  is  understood  that  the  surgeon  has  at  hand 
all  instruments  and  appliances  necessary  to  carry 
out  successfully  all  details  of  such  operation. 
All  preparations  having  been  previously  made  on 
the  part  to  be  operated  upon,  a  generous  skin  in- 
cision is  made,  just  overlying  the  point  of  frac- 
ture. "When  possible,  the  incision  should  be  made 
on  one  side  or  the  other  of  the  intended  bed  or 
site  of  the  transplant.  The  fascia  and  muscles 
overlying  the  point  of  fracture  are  opened  by  scal- 
pel and  blunt  dissection,  and  the  region  of  frac- 
ture well  exposed.  All  bleeding  vessels  are  ligated 
with  plain  catgut;  the  blood-clots  and  debris  are 
removed  from  the  ends  of  the  fragments.  Great 
caution  should  be  used  not  to  produce  any  more 
trauma  than  is  absolutely  necessar)'.  In  the  re- 
traction of  powerful  muscles  enough  trauma  has 
been  produced  to  cause  slough;  this  is  more  likely 
to  occur  when  a  short  incision  has  been  employed. 
Trauma  has  also  been  caused  by  the  careless  use 
of  the  motor  saws,  clamps,  elevators,  dull  instru- 
ments, etc.  A  skin  incision  of  sufficient  length,  or 
large  enough  to  give  ample  room  in  all  operative 
fracture   work,   is   very   essential. 

The  periosteum,  if  intact,  is  incised  with  the 
caliper  knives,  which  make  two  parallel  incisions. 
The  incisions  are  made  longitudinally,  and  the 
periosteal  strip  between  the  incision  is  cut  trans- 
versely. Then  the  periosteum  is  pulled  back  on 
either  side  to  inspect  the  broken  ends  of  the  bone. 


FOR   A    SUCCESSFUL   TRANSPLANT.  113 

In  fresh  fractures,  if  the  operator  has  decided 
to  use  the  inlay  graft,  material  for  such  graft  can 
as  a  rule  be  taken  from  the  fragments  themselves, 
unless  the  fracture  is  of  comminuted  type.  As  a 
rule,  a  graft  3"  to  4"  is  long  enough,  but  should 
the  surgeon  be  dealing  with  an  ununited  fracture, 
the  length  of  the  graft  depends  upon  the  amount 
of  eburnation.  In  ununited  fractures  the  graft 
should  extend  at  least  V2"  to  Y\"  into  healthy 
bone,   on   each   side  of   the   fracture. 

In  taking  the  graft  from  one  or  the  other  ends 
of  the  fresh  fractured  bone,  the  caliper  knives  are 
set  at  the  width  that  the  transplant  is  to  be  made; 
then  the}-  are  placed  over  the  proximal  end,  at  the 
seat  of  fracture,  and  drawn  up  towards  the  body 
from  4"  to  5",  in  a  straight  line.  They  will  make 
two  incisions  through  the  periosteum.  Xow  we 
use  the  periosteal  elevator  to  shove  the  periosteum 
back   on  either   side,   about   )/§'' '. 

"\Ye  now  place  the  caliper  knives  at  the  seat  of 
fracture,  over  the  distal  fragment  of  bone,  draw- 
ing them  down  the  bone  2"  to  2.y2" ';  we  again  use 
the  periosteal  elevator  to  push  back  the  periosteum. 
We  can  now  use  either  the  single  or  parallel 
saws  to  remove  the  graft  above  and  below  the 
fracture. 

The  author  prefers  the  single  saw,  on  account 
of  being  able  to  bevel  the  inlay  and  the  host  or 
bed,  so  that  the  inlay  will  not  fall  into  the  medul- 
lary cavity.  In  cutting  across  each  end  the 
author  uses  yi"  drill,  making  the  drill  holes  about 
Ys"    inch    apart    into    the    medulla,    after    which    a 


114 


MODERN    OPERATIVE    BOXE    SURGERY. 


sharp  chisel  is  used  to  cut  loose  the  graft  at  the 
end  still  intact.  AVe  now  slip  the  proximal  or 
long  graft  to  the  lower  end  of  the  bed,  giving 
us    a    continuous    bone   transplant    1^2"    below    and 


Fig.  59. — Illustrates  sliding-graft  being  removed  from  frag- 
ment (i)  and  graft  (j),  to  be  placed  in  space  (4)  and  equally 
divided  between  fragments  (1  and  2).  Piece  of  bone  (5)  to 
be  made  into  pegs  for  use  in  holding  graft  in  position,  as 
shown  in  Fig.  60. 

above  the  fracture,  bridging  across  the  seat  of 
fracture,  having  previously  removed  the  short 
graft   out   of   which   pegs   are   made   to   fasten    the 


Fig.  60. — Illustrates  the  sliding-graft  in  position,  bridging 
across  the  fractured  ends  of  bone.  The  short  graft  is  made 
into  pegs  to  hold  transplant  rigidly  in  place;  the  remaining 
fragments  of  bone  can  be  placed  in  that  portion  of  the  bed 
from  which  the  transplant  has  been  removed. 


inlay  in  position,  or,  in  other  words,  changing 
position  of  the  transplant — the  short  one  above, 
and  the  long  one  below. 

Pegs   are   far   superior   to   kangaroo   tendon  for 


FOR  A    SUCCESSFUL   TRANSPLANT.  115 

making  secure  the  graft  in  its  bed.  The  bone- 
pegs  are  made  Y%'r  in  diameter;  holes  are  made 
for  these  pegs  through  the  host  and  through  the 
graft  (as  shown  in  Fig.  60).  If  there  is  any 
bone  left,  we  take  and  place  it  in  the  hole  caused 
by  the  removal  of  the  long  graft  from  the  proxi- 
mal fragment  of  fractured  bone  into  its  new  bed. 
As  shown  in  Fig.  60,  bone-pegs  are  also  used  to 
fasten  small  fragments  in  position.  The  perios- 
teum should  be  protected  during  the  operation,  so 
that  all  parts  of  the  inlay  are  eventually  covered  by 
it.  I  believe  it  a  good  practice  to  sew  the  perios- 
teum covering  of  the  transplant  and  the  perios- 
teum of  the  recipient  bone  together.  By  this  ar- 
rangement the  periosteum  is  made  to  completely 
cover  the  transplant.  If  a  good  fit  of  the  trans- 
plant is  obtained,  and  the  work  is  done  in  proper 
manner,  the  inlay  always  lives,  grafts  itself  to 
the  adjacent  or  recipient  bone,  a  transformation 
takes  place,  and  the  result  is  that  it  becomes  a 
permanent  integral  part  of  the  recipient  bone,  the 
same    as    bone-pegs    or   intramedullary   dowels. 


CHAPTER  XVI. 

The  Use  of  an  Ixlay   Graft. 

The  inlay  transplant  can  only  be  used  in  cer- 
tain cases.  It  is  most  effective  where  osteogenesis 
of  the  end  of  the  broken  bones  is  to  a  certain 
extent  destroyed,  or  where  osteogenetic  action  is 
required.  I  believe  that  an  inlay  graft  is  prefer- 
able,    especially    when    taken    from    the     fractured 


/     fey  ^_)5\      x 

Fig.  61. — Cross-section  of  the  inlay  transplant  of  a  long 
bone,  showing  the  manner  of  its  fixation  by  bone-pegs.  Also 
shows  bevelled  edges  making  the  graft  wedge-shaped.  The 
motor  single  saw  is  used  in  removing  such  a  graft. 

ends  or  fragments  of  the  bone,  or  from  near  the 
location  where  it  is  transplanted:  and  the  inlay, 
as  it  does,  brings  periosteum  to  periosteum.,  cor- 
tical bone  to  cortical  bone,  endosteum  to  endos- 
teum.  etc.,  lives  and  grafts  more  readily  than  does 
an    intramedullary    dowel    (Fig.    6l). 

An  inlay  graft  should  comprise  four  different 
tissues,  namely,  periosteum,  compact  bone,  endos- 
teum. and  marrow  substance.  The  inlay  method 
is  the  only  method  that  permits  coaptation  of  each 
of  these  individual  elements  to  those  of  the  re- 
ill6» 


THE   USE    OF   AN    INLAY    GRAFT.  117 

cipient  bone.  An  inlay  graft,  however,  is  limited 
in  its  application.  In  a  vicious  fracture  that  re- 
quires considerable  strength  to  hold  it  in  position, 
the  intramedullary  dowel  is  much  superior;  in 
fact,  it  would  not  be  good  surgery  to  use  any 
other  means  of  internal  fixation  in  such  condition. 
The  inlay  transplant  does  not  furnish  sufficient 
strength  of  fixation  to  be  reliable  in  fractures  of 
unsupported  single  long  bones.  It  is  a  matter 
for    the    surgeon    to    decide    whether    bone-pegs    or 


Fig.  62. — Cross-section  of  long  bone  with  rectangular  inlay 
graft  held  in  position  by  bone-pegs.  Graft  may  be  removed  by 
either  parallel  or  twin  saws. 

kangaroo  tendons  are  used  to  fasten  the  inlay  to 
the  recipient  bone  (Fig.  62).  Extreme  caution 
must  be  used  in  applying  the  outer  fixation  or 
plaster  cast.  The  fixation  of  the  inlay,  however, 
is  very  materially  increased  by  the  use  of  bone- 
pegs  in  holding  the  transplant  in  position.  Should 
the  pegs  holding  the  inlay  in  position  be  broken 
during  the  application  of  the  outer  dressing,  dis- 
placement of  the  graft  is  almost  sure  to  occur; 
or  should  the  outer  dressing  or  plaster  cast  not 
be  snugly  applied,   on  moving  the  limb,   or  should 


118  MODERN    OPERATIVE    BONE   SURGERY. 

spasmodic  contraction  occur,  motion  will  be  given 
to  the  fragments,  and  the  desired  results  from  the 
inlay  will  not  likely  follow.  So  it  is  of  great 
importance  that  the  plaster  cast  be  applied  snugly 
to  the  fractured  limb,  and  cover  at  least  one  joint 
above  and  one  below  the  fracture. 

The  inlay  graft  is  more  suitable,  however,  for 
fracture  of  one  of  two  parallel  bones,  where  one 
of  the  bones  is  still  intact,  viz.,  fracture  of  the 
shaft  of  the  tibia,  where  the  fibula  is  not  broken, 
or  in  fracture  of  the  radius,  where  the  ulna  is 
still   intact,  or  vice  versa. 

The  open  method,  or  osteoplastic  work,  should 
be  done  if  possible  immediately  after  the  injury, 
as  a  primary  reduction  and  fixation.  If  it  is  im- 
possible to  do  it  at  this  time,  it  should  be  delayed 
until  all  acute  symptoms  of  traumatism  from  the 
fracture    or    efforts    at    reduction   have    subsided. 

In  case  of  fresh  fracture,  as  above  stated,  the 
bone  being  normal,  the  material  for  the  inlay  can 
be  taken  from  the  fragments  themselves,  and  used 
as  the  material  for  the  graft.  This  as  well  as 
other  similar  transplant  technic  would  be  difficult 
and   laborious   without   the   use   of   the  motor   saw. 

A  very  important  point  to  be  always  borne  in 
mind  in  osteoplasty  (replacing  shaft  of  bone  by 
graft)  is,  that  it  matters  not  how  small  the 
graft,  it  will  in  time  hypertrophy  under  the  action 
of  Wolff's  law,  and  will  become  the  size  and 
strength  of  the  bone  it  represents,  or  whose  sub- 
stance it  is  supplying.  The  value  of  the  graft  in 
this  type  of  case   cannot  be  overestimated. 


THE   USE   OF   AN    INLAY    GRAFT.  119 

In  the  technic  of  bone-grafting  it  is  an  impor- 
tant point  that  in  all  types  of  fractures  the  trans- 
plant should  be  of  sufficient  length  to  serve  the 
requirements    of    each    and    every    individual    case. 

In  the  case  of  an  intramedullary  graft  4"  long, 
this  might  afford  a  great  deal  of  difficulty  in  its 
application  under  certain  conditions,  but  an  inlay 
graft  4"  long  can  be  inlaid  as  easily  as  one  2" 
long.  In  a  great  many  cases  the  success  of  the 
transplant  depends  upon  the  length  of  the  graft, 
it  matters  not  whether  it  is  an  inlay  or  an  intra- 
medullary dowel.  The  conditions  calling  for  the 
application  of  the  intramedullary  dowel  are  much 
more  numerous  than  those  of  the  inlay.  As  in 
almost  all  acute  fractures,  the  symptom  most  fre- 
quently demanding  open  treatment  is  a  persistent 
deformity,  or  when  the  broken  ends  of  the  bone 
are  unable  to  be  kept  in  position  by  external  fixa- 
tion. The  above  condition  demands  the  applica- 
tion of  some  internal  fixation  or  means  of  per- 
fecting the  anatomical  relations  of  the  fractured 
ends  of  the  bone  or  bones.  The  intramedullary 
dowel  is  much  superior  to  the  inlay  for  such  pur- 
pose. In  fact,  the  bone  cannot  well  be  out  of 
alignment  or  its  anatomical  relations  be  other  than 
fairly  correct,  if  the  intramedullary  dowel  is 
properly   applied. 


CHAPTER  XVII. 

Technic  Used  in  Applying  the  Intra- 
medullary Dowel. 

The  technic  for  the  application  of  the  intra- 
medullary dowel  is  as  follows:  An  incision  is 
made  over  the  fracture;  the  broken  ends  of  the 
bone  are  exposed;  the  blood-clots  and  other 
products  of  the  traumatism  are  removed  from  and 
around  the  seat  of  fracture,  with  as  little  disturb- 
ance to  the  periosteum  as  possible;  the  medullary 
cavity  of  each  fragment  is  cleaned  of  that  part  of 
the  marrow  which  has  been  disturbed  by  trauma- 
tism, hemorrhage  or  inflammation,  with  a  bone 
curette,  and  squared  with  a  chisel  to  the  size  of 
the  dowel  to  be  used. 

The  fractured  ends  of  the  bone  are  exposed 
or  approached  in  the  same  manner  as  when  the 
inlay  is  employed.  After  bringing  the  ends  of  the 
fractured  bones  into  view,  the  caliper  knives  are 
used  to  find  out  the  exact  size  of  the  intramedul- 
lary cavity.  The  size  of  the  dowel  depends  upon 
the  size  of  the  medulla.  Having  decided  upon  the 
size  of  the  dowel,  a  chisel  the  size  of  the  diameter 
of  the  graft  is  used  to  square  the  medullary  cavity. 
If  the  intramedullary  dowel,  ^2"  in  diameter,  is  to 
be  used,  or  a  piece  of  bone  V2"  rectangular,  a  V2" 
chisel  would  be  used.  It  is  of  great  importance  that  a 
dowel  be  neither  too  loose  nor  too  tight;  as  pre- 
viouslv  stated,  we  must  have  perfect  contact  of 
(120) 


APPLYING   THE   INTRAMEDULLARY    DOWEL        121 

the  graft  and  the  recipient  bone.  If  the  graft 
fits  too  tight,  pressure  necrosis  is  liable  to  follow; 
so  it  is  just  as  important  not  to  have  it  too  tight 
as  not  to  have  it  too  loose.  The  great  trouble  that 
novices  have  in  the  application  of  the  intramed- 
ullary dowel  is,  after  the  graft  has  been  placed 
in  the  distal  end  of  the  bone,  to  place  it  in  the 
proximal  end.  This,  however,  is  very  easy  to 
accomplish,  if  the  graft  fits  as  it  should.  Say  the 
graft  is  5"  in  length,  it  is  introduced  into  the  distal 
bone  fragment  from  3"  to  4".  Forcible  extension 
is  made  on  the  limb;  the  protruding  end  of  the 
dowel  is  round.  The  limb  is  placed  in  such  posi- 
tion that  the  graft  is  brought  into  the  most  acces- 
sible point  of  entrance  into  the  medulla  of  the 
proximal  bone  fragment ;  the  graft  being  rectangular, 
after  it  once  enters,  the  fragments  cannot  be 
rotated  on  one  another,  and  at  once  the  ends  of 
the  bones  are  brought  into  a  perfect  anatom- 
ical relation.  Half  of  the  dowel  is  now  placed 
in  the  approximal  end  of  the  fractured  bone,  by 
the  use  of  a  sharp-pointed  instrument.  Great  care 
must  be  taken,  as  in  all  plastic  bone  work,  not 
to  allow  anything  that  comes  in  contact  with  the 
skin  covering  the  part  operated  upon  to  come  in 
contact  with  the  graft  or  the  ends  of  the  broken 
bone.  The  periosteum  should  be  closed  with  some 
absorbable  material,  as  plain  gut.  The  soft  parts 
should  be  brought  in  contact,  layer  by  layer.  Care 
must  be  taken  not  to  draw  the  stitches  tight 
enough  to  produce  pressure  necrosis.  The  skin 
is    closed    with    plain    catgut,    subcuticular    stitch. 


122  MODERN    OPERATIVE   BONE    SURGERY. 

Twenty  layers  or  more  of  plain  gauze  are  applied 
over  the  wound,  over  which  is'  placed  a  gauze 
bandage;  we  now  proceed  to  apply  the  external- 
fixation  dressing.  Plaster-of-Paris  is  most  com- 
monly used.  It  must  be  impressed  that  the  great- 
est of  care  must  be  exercised  in  the  application 
of  the  outer  dressing,  for  the  slightest  false  motion 
will  sometimes  break  the  dowel,  and  absolutely 
destroy    the    desired    results    of    the    operation. 

To  repeat,  the  more  compact  the  bone-graft, 
the  better  it  serves  as  a  transplant.  The  most 
available  material  of  such  character  is  found  in 
the  tibia  or  fibula.  The  transplant  must  be  long 
enough  to  extend  at:  least  i"  to  1^2"  beyond  the 
irregularities  of  the  line  of  fracture,  or  into 
healthy  bone.  Its  thickness  should  be  sufficient  to 
make  bony  contact  with  the  entire  circumference  of 
the  interior  of  the  shaft.  The  dowel,  after  intro- 
duction, should  not  bind;  it  should  be  loose  enough 
to  facilitate  its  nutrient  supply  and  avoid  pres- 
sure-necrosis as  formerly  suggested.  It  matters 
not  how  small  nor  how  large  the  intramedullary 
dowel  is,  the  periosteum  should  be  removed  al- 
ways, when  and  zvherever  the  graft  is  bnried  in 
bone.  The  periosteum  would  prevent  bone-to-bone 
contact,  which  is  necessary  for  the  grafting  pro- 
cess. All  fragments  of  bone  torn  loose  from  the 
periosteum  by  the  injury  at  the  point  of  fracture, 
and  Wing  for  considerable  length  of  time  in  the 
debris,  blood,  etc.,  are  dead  bone,  and  are  not 
proper  material  for  transplanting. 

For  continued  success   in  osteoplasty,   the  graft 


APPLYING   THE   INTRAMEDULLARY   DOWEL.        123 

should  be  autogenous  living  bone,  and  placed  in 
its  new  environment  quickly  before  its  supply  of 
nutrition  has  been  exhausted  or  destroyed.  If  all 
conditions  are  favorable,  the  transplant  becomes 
transformed  into  a  living  integral  portion  of  the 
repaired  bone,  serving  its  part  in  the  functional 
support  of  the  extremity,  and  maintaining  for  a 
time  its  shape  and  size.  Later,  like  any  other 
portion  of  the  skeleton,  it  becomes  modified  by 
the  condition,  and  functional  demands  upon  it.  It 
remains  as  long  as  its  support  is  required,  after- 
which  the  superfluous  part  is  absorbed,  and  grad- 
ually the  medullary  canal  is  partially  re-established. 
Should  the  transplant  and  recipient  bone  not  have 
bony  contact,  fibrous  union  between  them  may  be 
expected,  and  after  union  of  the  fracture  the  trans- 
plant becomes  absorbed.  Should  the  transplant 
die  because  of  scanty  nutrition,  it  would  become 
encapsulated  and  absorbed  long  after  the  union  of 
the   fracture. 


CHAPTER  XVIII. 

The  Bone-peg  in  Cortical  Bone. 

The  peg  transplant  in  cortical  bone,  like  the 
inlay  and  dowel  inserts,  has  its  field  of  usefulness, 
i.e.,  fractures  of  the  ends  of  the  long  bones,  con- 
dyles, protuberances,  irregular  bones,  as  the  os  cal- 
cis,  or,  in  fact,  in  fracture  of  any  bone  where 
there  is  no  medullary  canal.  The  fractured  area 
is  exposed  in  the  same  manner,  and  the  same 
technic  is  used  as  in  the  application  of  the  intra- 
medullary dowel.  In  each  and  every  case  a  pecul- 
iar plan  is  adopted  for  the  application  of  the  bone- 
graft  or  peg,  that  will  best  retain  the  fragments 
in  position.  The  space  that  the  bone  peg  must 
bridge  is  measured,  and  the  size  of  the  graft 
necessary  is  estimated.  The  proper  size  and  length 
transplant  is  obtained  from  above  or  below  frac- 
ture or  from  the  tibia  or  fibula,  without  periosteum. 
It  must  be  of  one  size  the  entire  length,  not 
tapering.  The  fragments  are  ahvays  first  placed 
in  position  and  the  hole  bored  through  them  with 
the  same  size  drill  as  the  peg  which  is  to  be 
used.  The  points  of  contact  with  compact  bone 
are  secured  wherever  possible,  for  a  leverage  and 
center  of  gravity.  The  opening  through  the  com- 
pact bone  must  be  of  sufficient  size  to  allow  the 
transplant  to  be  placed  in  position  without  bind- 
ing. The  peg  will  hold  the  fragments  in  position 
(124) 


THE    BONE-PEG   IN    CORTICAL   BONE.  125 

without  being  driven  tightly.  When  the  fragments 
and  transplant  are  in  position  the  latter  will  be 
in  contact  with  both  the  cancellous  bone  on  the 
inside  and  the  compact  bone  externally,  which 
furnishes  a  temporary  support  to  the  fractured 
bone,    and    favorable    conditions    for    grafting. 

The  part  of  the  transplant  which  is  buried  in  the 
cancellous  bone  stimulates  osteogenesis.  The  growth 
of  new  bone  spreads  from  it,  and  infiltrates  the 
contacting  bone,  until  it  merges  into  a  continuous 
bone-mass,  across  the  line  of  fracture.  This  new 
bone  increases  in  solidity  and  strength  according 
to  the  functional  demands  upon  it,  taking  its  part 
in  the  support  of  the  body.  Later  on  the  graft 
is  modified  and  absorbed,  as  the  necessity  of  sup- 
port is  relieved  by  the  bony  union  between  the 
ends  of  the   fractured  bone. 


CHAPTER  XIX. 

Things   Essential   in   Treating   Fractures. 

A  perfect  knowledge  of  anatomy,  an  accurate 
observation,  combined  with  simplicity  in  mechanical 
methods,  will  always  be  recognized  as  a  perfect 
basis  for  the  treatment  of  fractures. 

The  great  certainty  of  the  diagnosis  gained  by 
the  application  of  the  Rontgen  rays  has  suggested 
more  direct  and  simple  methods  in  the  treatment 
of  fractures,  and  also  has  contributed  much 
towards  an  actual  interpretation  of  the  physical 
signs. 

The  Rontgen  rays  serve  a  double  purpose,  by 
confirming  the  diagnosis  of  the  fracture,  and 
also  giving  much  information  as  to  its  nature.  It 
is  an  acknowledged  fact  that  in  fracture  work  the 
X-ray  is  indispensable,  for  the  surgeon  can  see  at 
a  glance  the  relations  the  ends  of  the  bones  bear 
to  each  other,  and  thereby  can  place  the  ends  of 
the  bones  in  proper  position.  Therefore  it  gives 
the  surgeon  the  "key"  to  the  real  diagnosis  and 
correct   treatment. 

Every  surgeon  who  is  called  upon  to  treat 
fractures  should  be  provided  with  a  portable 
X-ray,  bandages,  splints,  plaster-of-Paris,  etc.  He 
should  not  be  obliged  to  gather  the  material  to- 
gether at  the  time  it  is  needed.  Especially  is  this 
true  if  he  treats  the  patient  at  his  or  her  home. 
(126) 


THIXGS   ESSENTIAL   IN    TREATING   FRACTURES.    127 

The  ordinary  or  simple  fracture,  as  a  rule,  is 
a  very  easy  and   simple   condition   to   treat. 

One  of  the  most  important  things  in  the  treat- 
ment of  fractures  is  the  proper  adjustment,  or 
placing  the  ends  of  the  bone  in  perfect  apposition. 
The  next  most  important  step  is  the  application 
of  the  splint  or  dressing,  being  careful  not  to 
have  it  too  tight  or  too  loose,  and  always  using 
an  abundance  of  surgeon's  wadding,  placing  it  the 
same  thickness   over   the   entire   surface. 

Should  the  fracture  be  an  oblique  one,  that 
cannot  be  held  in  apposition  (or  almost  any  form 
of  vicious  fracture),  it  is  advisable  to  use  the 
open  method. 

With  the  splendid  technic  and  equipment  now 
used  by  bone  surgeons  throughout  the  land,  a 
very  interesting  field  has  been  opened  to  surgery 
in  the  treatment  of  a  certain  class  of  fractures. 
The  indications  for  the  open  treatment  in  fresh 
fractures  and  ununited  fractures  are  entirely  dif- 
ferent. It  is  a  very  evident  fact  that  the  large 
number  of  practitioners  do  not  appreciate  this 
difference. 

In  a  large  percentage  of  fresh  fractures  tem- 
porary fixation  alone  is  necessary  to  insure  union, 
as  the  osteogenetic  function  of  the  fragments  or 
fractured  ends  are  active,  and  in  the  presence  of 
accurate  apposition  union  occurs  rapidly. 

In  ununited  fractures  the  problem  is  quite  dif- 
ferent. We  have  here  in  the  ends  of  the  frag- 
ments a  marked  diminution  or  an  entire  cessation 
or    destruction    of    the    bone-growing    elements    or 


128  MODERN    OPERATIVE   BONE    SURGERY. 

osteogenetic  activity.  This  cessation  of  activity  is 
evidenced  by  the  marked  sclerosis  or  eburnation 
which  always   is   in   evidence. 

The  pathology  of  this  condition  of  sclerosis  is 
very  similar  to  that  found  in  non-ankylosing 
osteoarthritis,  where  there  is  an  overdeposit  of 
calcium  salts,  and  a  consequent  diminution  and  de- 
generation  of   the  bone-producing  cells. 

Abundant  evidence  has  been  accumulated  to 
prove  that  something  more  than  fixation  is  essen- 
tial in  these  conditions,  as  the  most  favorable 
cases  of  external  fixation  have  failed  to  unite  in 
spite  of  months  of  effectual  artificial  or  external 
splinting. 

It  has  been  suggested,  to  meet  the  above  thera- 
peutical requirements,  that  spanning  of  the  frac- 
tured area  with  a  very  thin  autogenous  periosteal 
graft  has  given  a  fair  percentage  of  good  results, 
but  it  is  not  an  ideal  procedure  in  that  it  does  not 
furnish  efficient  fixation.  It  does  not  stimulate 
osteogenesis  between  the  ends  of  the  fragments; 
it  is  entirely  superficial,  and  does  not  penetrate 
cortical  bone-structure;  therefore  it  furnishes  an 
imperfect  graft   environment. 

The  inlay  graft  or  cortical  bone  transplant 
not  only  affords  a  fair  fixation,  but  also  furnishes 
the  most  ideal  environment  for  the  bone-grafting; 
it  brings  each  layer  of  bone  in  close  apposition 
with  its  corresponding  layer — periosteum  to  perios- 
teum, compact  bone  to  compact  bone,  endosteum  to 
endosteum,   etc. 

The     intramedullary     dowel      is      an      excellent 


THINGS    ESSENTIAL   IN    TREATING   FRACTURES.    129 

method,  which  gives  almost  perfect  fixation,  and, 
being  entirely  osseous,  favors  stimulation  of  osteo- 
genesis, when  there  is  good  contact  of  the  graft 
to  the   recipient   fragments. 

Bone  surgery  should  not  be  attempted  without 
perfect  equipment.  Transplanting  of  bone  should 
be  restricted  to  wherever  the  closed  method  will 
not  give  good  results,  and  also  in  those  cases  that 
apparently  will  be  exceedingly  delayed  in  union. 

I  believe  that  the  operation  or  open  treatment 
of  fractures  will  find  as  broad  a  field  for  itself  in 
the  near  future  as  has  the  operation  for  the  radi- 
cal  cure   of   hernia. 

In  almost  all  of  the  textbooks  on  general  sur- 
gery advice  is  given  in  simple  fractures  to  delay 
the  operation  for  at  least  one  week;  in  compound 
fractures  a  longer  time — two  weeks  or  longer. 
Advice  is  also  given  not  to  remove  blood-clots; 
the  reason  given  for  not  removing  clots  and 
shreds  of  tissue  is  that  they  act  as  irritants,  and 
thereby  aid  in  the  formation  of  callus.  This  is 
erroneous.  You  would  not  leave  a  blood-clot  at 
the  seat  of  any  fracture  any  more  than  you  would 
leave  it  in  a  wound  in  the  abdomen. 

The  time  to  operate  in  all  fractures  excepting 
compound,  if  operation  is  decided  upon,  is  the 
soonest  possible  moment  that  you  can  get  the  pa- 
tient prepared.  Jones  has  well  said  that  if  a  sur- 
geon is  doubtful  whether  he  can  treat  a  fracture 
effectively  by  non-operative  means,  he  ought  to 
consider  whether  he  can  do  better  by  using  the 
open  method  at   once.     He   should  not   say   "Well, 


130  MODERN    OPERATIVE   BONE    SURGERY. 

we  can  see  what  will  become  of  it,  and  if  it  is 
not  satisfactory  we  can  operate  later,"  for  by  so 
doing  the  only  opportunity  of  getting"  a  good 
functional    result   is   irretrievably  lost. 

The  necessity  of  open  treatment  should  be 
recognized  as  soon  as  possible.  PRACTICALLY 
EVERY  TYPE  OF  FRACTURE  NEEDS  OPER- 
ATIVE INTERFERENCE,  IF  COMPLETE  RE- 
DUCTION IS  OTHERWISE  UNFEASIBLE. 
As  previously  stated,  the  X-ray  obviates  many 
difficulties   in   determining  this   fact. 


CHAPTER    XX. 

The  Time  to  Operate  ox   Fresh   Fractures. 

The  most  favorable  time  for  intervention  in 
fractures  that  cannot  be  held  in  apposition  by  the 
ordinary  methods  is  at  once,  after  such  condi- 
tion has  been  discovered,  or  as  soon  as  the 
patient  can  be  gotten  in  suitable  surroundings,  and 
properly  prepared,  and  when  the  condition  of  the 
patient  will  permit.  If  not  within  a  day  or  two 
after  the  accident  you  should  wait  seven  to  ten 
days  after  the  fracture  occurred,  or  until  all  in- 
flammation resulting  from  trauma  has  subsided. 
As  previously  stated,  for  compound  fractures,  in 
the  majority  of  cases,  on  account  of  infection,  it 
is  advisable  to  wait  until  the  wound  of  the  soft 
parts  has  entirely  healed,  after  which  time  good 
results  can  be  obtained,  if  the  open  method  is 
used. 

For  clinical  purposes,  simple  fractures  may  be 
divided   into   three   groups : — 

Group  i.  Fractures  that  can  be  reduced  by 
manipulation,  and  held  in  perfect  position  by  ex- 
ternal fixation;  in  such  cases  the  open  method  is 
counterindicated.  In  this  verv  large  group  of 
fractures  good  functional  and  anatomical  results 
may  be,  and  are,  obtained  by  the  external  method. 

Group  2.  Fractures  where  the  fragments  can- 
not  be    reduced    by    external    manipulation    to    per- 

(131) 


132  MODERN    OPERATIVE   BONE    SURGERY. 

feet  anatomical  relations.  The  fractured  ends 
should  be  exposed  by  an  incision,  and  the  broken 
ends  of  the  bone  placed  in  proper  position.  After 
reduction  has  been  perfected,  if  the  fractured  ends 
can  safely  and  securely  be  immobilized  by  exter- 
nal fixation,  internal  fixation  is  not  required. 

Group  3.  Fractures  where  it  is  necessary  to  ex- 
pose the  fractured  ends  by  an  incision  to  bring 
about  a  proper  reduction,  and  where  it  requires 
internal  alignment  and  both  internal  and  external 
fixation  or  immobilization  to  secure  the  desired 
results. 

The  execution  of  the  technic  involved  in  the 
application  of  the  bone-graft  necessary  to  assure 
success,  and  many  of  the  conditions  that  I 
have  enumerated,  would  be  difficult,  slow,  and  in- 
accurate, except  for  the  application  of  the  electric 
motor  and  attachments,  such  as  twin  saws,  drills, 
burrs,  and  doweling  instruments.  These  save  time, 
avoid  trauma,  both  to  the  bone  and  soft  parts, 
favor  precision  in  modeling  the  graft  and  prepar- 
ing its  bed,  and  simplify  and  make  easy  the  tech- 
nic in  deep  wounds  and  regions  difficult  to  get  at 
with  hand  instruments. 

Crile  says  that  the  motor  instruments  diminish 
shock,  on  account  of  the  lessened  excitation  of  the 
efferent  nerves  by  the  rapid  movement,  and  con- 
sequently the  minimum  disturbance  is  caused  to 
nerve    center. 

However,  it  is  evident  that  the  shock  formerly 
experienced  in  bone  work  has  largely  if  not  entirely 
disappeared  since  the  development  and  use  of  the 
motor    instruments.     Whether    this    is    due    to    the 


TIME  TO  OPERATE  ON  FRESH  FRACTURES.   133 

marked  shortening  of  the  time  required  for  opera- 
tion or  to  the  Crile  theory,  or  both,  and  in  what 
proportion,    it  is   very   difficult   to  determine. 

It  cannot  be  too  often  mentioned  that  bone  sur- 
gery does  require  a  special  technic.  Vigorous 
aseptic  precautions  in  preparation  of  the  operative 
field,  the  surgeon,  and  his  assistants  are  absolutely 
essential. 

The  fractured  ends  of  the  bone  should  always 
be  exposed  by  a  generous  incision.  The  skin  and 
subcutaneous  tissues  are  retracted.  In  an  ununited 
fracture,  the  firm  adhesions  between  the  ends  of 
the  bone  are  now  easily  relieved,  or  broken  up, 
with  the  author's  elevating  spoon  or  skid  (Fig. 
48).  When  released,  the  ends  of  the  bone  are 
held  firmly  with  the  author's  bone  elevating  for- 
ceps (Fig.  47).  The  ends  are  now  developed  or 
freshened  with  the  motor  burr  or  saw,  and  the 
sclerosed  plug  is  removed  from  the  medullary 
canal  with  the  author's  special  sharp-nose  burr. 
If  the  dowel  is  used,  should  there  be  an  over- 
lapping of  the  fragments,  the  amount  of  pulling 
necessary  to  correct  it  varies  with  the  strength 
of  the  patient,  and  the  deg'ree  of  overlapping.  As 
soon  as  the  extension  is  sufficient  to  overcome  the 
overlapping",  the  ends  of  the  bone  are  brought  in 
apposition,  and  we  must  now  decide  if  we  are 
to   use   the    intramedullary   dowel    or    the    inlay. 

Should  we  decide  to  use  the  rectangular  dowel  or 
peg,  we  would  enlarge  the  medulla  with  the  motor 
drill  and  chisel  large  enough  to  receive  the  graft. 
All  preparations  having-  been  previously  made,   the 


134  MODERX    OPERATIVE    BOXE    SURGERY. 

graft  is  now  removed  from  the  selected  field — 
from  the  shaft  of  the  fractured  bone,  or,  if  from 
the  tibia,  the  anterior  and  inner  portion  thereof  is 
preferable.  Single  or  parallel  motor  saws  are  used 
to  sever  the  graft  from  its  maternal  bed,  and  it  is 
then  grasped  with  the  author's  graft-retaining  for- 
ceps   (Fig.   44),   and   lifted   from   its   mother-bed. 

This  forceps  is  made  with  a  rachet,  and  the 
graft  once  in  the  jaws  of  the  forceps  is  held 
firmly  until  released.  This  is  quite  essential,  as 
many  a  transplant  has  been  dropped,  and  it  is 
then  absolutely  worthless  thereafter.  Xot  only 
does  this  forceps  safely  hold  the  graft,  but 
makes  easy  the  placing  of  it  in  its  future  bed. 
The  dowel  should  fit  snugly  in  both  ends  of  the 
bone.  Before  placing  the  dowel  in  position,  a 
thorough  examination  should  be  again  made  of 
the  medulla  to  see  that  there  is  no  oozing,  for  a 
hematoma  of  considerable  size  means  death  to  the 
transplant. 

If  using  the  inlay,  the  fractured  ends  are  held 
in  good  alignment  by  the  author's  bone  clamp 
(Fig.  49).  The  periosteum  is  divided  with  the 
caliper  knives,  longitudinally,  over  the  bone  to  be 
removed  for  the  bed  of  the  graft.  It  is  then 
pushed  out  of  the  way  of  the  saws,  making  a 
gutter  for  the  bone  inserted,  for  which  we  would 
use  either  the  single  or  twin  saws,  and  we  would 
also  use  the  same  saws  to  cut  out  the  graft  or 
inlay,  in  some  cases  using  as  small  a  graft  as 
?'ic"  in  width,  and  in  others  as  large  a  one  as  %" 
wide,   or   even   wider. 


TIME  TO  OPERATE  ON  FRESH  FRACTURES.   135 

The  exact  length  of  the  insert  is  obtained  by 
measuring  the  gutter.  If  the  length  is  correct, 
the  inlay  should  fit  accurately.  The  transplant 
can  be  fastened  with  bone-pegs  or  kangaroo  ten- 
don, the  holes  being  made  through  the  ends  of  the 
bone,   and   the   inlay,   with   the   motor   drill. 

It  is  readily  seen  that  this  not  only  affords  a 
fair  fixation,  but  also  furnishes  the  most  ideal  en- 
vironment for  the  bone-graft.  It  brings  each  layer 
of  bone  into  close  apposition  with  its  correspond- 
ing layer,   or  in  contact  with  each   other. 

The  periosteal  covering  of  the  transplant  and 
the  periosteum  covering  the  fractured  ends  are 
sewed  together  with  chromic  gut;  the  skin  is 
closed  with  plain  gut,  subcuticular;  and  the  wound 
is  covered  with  plain  gauze.  A  fixed  dressing 
is  now  applied  which  is  not  disturbed  for  4  to  6 
weeks,   unless  we  have  a   rise  of  temperature. 

In  summing  up,  the  things  most  important  are: 
(1)  careful  examination  and  diagnosis;  (2)  if 
simple  fracture,  bringing  the  ends  of  the  frac- 
tured bone  into  perfect  apposition  by  manipulation 
if  possible,  if  not,  then  use  operative  means;  (3) 
choosing  of  the  dressing  used,  splints  or  plaster- 
of-Paris;  (4)  application  of  dressing,  being  sure 
that  just  the  right  pressure  is  used,  not  too  tight 
or  too  loose;  (5)  if  the  open  method  is  used 
there  must  be  perfect  technic,  for  unless  the  tech- 
nic  is  perfect  good  results  cannot  be  obtained; 
perfect  technic  is  impossible  without  thorough 
equipment,  and  suitable  surroundings;  (6)  careful 
reparation,  with  as  little  trauma  as  possible,  of  the 


136  MODERN    OPERATIVE    BONE    SURGERY. 

soft  parts,  ends  of  the  bone,  and  inlay  or  dowel; 
(7)  a  well-fitting  graft  which  aids  osteogenesis, 
gives  perfect  fixation,  and  prevents  bleeding  or 
formation  of  hematome,  which  would  cause  death 
of  the  graft;  (8)  in  case  of  an  inlay  graft,  care- 
ful preservation  of  the  periosteum,  which  aids  the 
blood-supply,  and  the  blood-supply  to  a  graft 
means  life,  and  life  means  success. 

In  ununited  fractures,  or  in  pseudoarthrosis,  of 
the  long  bone,  where  the  surgeon  anticipates 
trouble  in  holding  the  bone  in  position,  it  is  then 
advisable  to  use  the  intramedullary  dowel.  On 
the  other  hand,  if  the  bone  is  easily  held  in  place, 
the  inlay  graft  is  preferable;  for,  as  previously 
stated,  the  inlay  transplant  carries  with  it  greater 
osteogenetic  power  than  does  the  intramedullary 
dowel,  because  it  is  applied  with  the  periosteum, 
compact  bone,  endosteum,  and  marrow  intact,  and 
that  it  contacts  with  tissue  of  like  consistency. 
Under  such  environments,  the  transplant  lives  and 
grafts  more  readily  than  it  does  under  other 
conditions. 

In  either  pseudoarthrosis,  or  ununited  fractures, 
the  graft  varies  in  length  from  3"  to  7",  gov- 
erned by  the  size  of  the  bone  fractures  and  the 
extent  of  the  impairment  of  osteogenetic  proper- 
ties, the  extent  of  comminution,  the  age  of  the 
fracture,  and  the  amount  of  osteoporosis  in  the 
fractured  ends.  If  the  fracture  is  of  long  stand- 
ing, it  is  essential  to  obtain  the  transplant  from 
above  or  below  the  break,  or  from  the  tibia.  The 
recipient   bone    should   be   prepared   first.      In   fact, 


TIME  TO  OPERATE  ON  FRESH  FRACTURES.   137 

it  matters  not  from  what  location  the  graft  is  re- 
moved from  the  shaft  of  the  injured  bone  or  from 
any  distal  bone  of  the  body;  the  above  technic 
should   always   be   carried   out. 

Great  care  should  always  be  taken  to  protect 
the  graft-bed  and  surrounding  tissues  by  covering 
them  with  gauze  wrung  out  of  normal  salt  solu- 
tion, while  removing-  the  graft  from  the  shaft  of 
the  bone,  above  or  below  the  fracture,  or  from  the 
tibia,  or  whatever  bone  selected.  Again,  the  fact 
should  be  emphasized  of  the  great  importance  of 
the  properly  fitting  transplant,  whether  it  is  inlay 
or  intramedullary  dowel.  The  above  is  easily  ac- 
complished if  the  operator  will  use  the  caliper 
knives  (Fig.  38),  setting  them  at  the  width  de- 
sired for  cutting  through  the  periosteum  covering 
the  bone  to  be  removed   for  grafting  purposes. 

It  is  optional  with  the  surgeon  whether  he 
uses  the  single  or  twin  saws.  When  the  graft 
and  its  gutter  or  bed  are  formed  wholly  by  the 
twin  saws,  the  graft  is  somewhat  narrower  than 
the  gutter ;  in  fact  it  is  as  much  narrower  as  the 
two   furrows   cut  by  the  two   saws. 

For  my  part,  I  would  much  prefer  to  remove 
an  inlay  graft  with  the  single  saw,  because  the  in- 
lay should  be  cut  on  a  bevel;  otherwise  it  could 
not  be  made  to  fit  snugly,  which  is  very  impor- 
tant. 

The  intramedullary  grafts  are  preferably  re- 
moved by  the  twin  or  parallel  saws,  because  the 
width  is  exactly  the  same  the  entire  length  of  the 
graft  when  the  parallel  saws  are  used.     However, 


138  MODERX    OPERATIVE    BOXE    SURGERY. 

if  the  surgeon  is  familiar  with  such  work,  he  can 
be  almost  as  accurate  with  the  single  saw,  in  cut- 
ting" a  graft  of  uniform  width,  as  with  the  twin 
saws. 

After  removing  transplants  from  the  tibia,  or 
other  bones,  unless  great  precaution  is  used,  frac- 
ture of  such  bone  may  occur;  especially  is  this 
true  if  a  considerable  portion  of  the  surface  is  re- 
moved. Several  rontgenograms  were  exhibited  at 
a  recent  meeting  of  the  American  Rontgen  Ray 
Society  of  such  cases.  A  plaster  cast  should  al- 
ways be  applied  to  the  limb  to  protect  it  during 
the  entire  period  of  regeneration  of  bone  caused 
by  the  removal  of  the  transplant.  Adequate  sup- 
port or  protection  should  be  continued  for  at  least 
six  weeks ;  even  then  the  patient  should  be  cau- 
tioned in   regard  to  the  use  of  the  limb. 

From  whatever  bone  the  graft  is  removed  for 
transplantation,  it  is  replaced  by  a  deposit  of  new 
bone.  The  rapidity  with  which  it  is  re-established 
depends  upon  the  age  and  physical  condition  of 
the  patient,  and  upon  the  size  of  the  defect.  As 
a  rule,  nature  readily  responds  to  functional  de- 
mands for  strength.  Bone  is  regenerated  in  the 
defect  caused  by  the  removal  of  the  transplant, 
and  the  remaining*  bone  hypertrophies  until  the 
equilibrium  between  function  and  strength  has 
been  re-established.  If  the  whole  segment  is  re- 
moved for  transplantation,  regeneration  is  more 
uncertain.  When  the  epiphyses  are  undisturbed, 
and  if  the  periosteum  is  not  too  extensively  lacer- 
ated or  bruised,   and  left  in  position,  there  may  be 


TIME  TO  OPERATE  OX  FRESH  FRACTURES.   139 

regeneration  of  the  entire  shaft  of  such  bone.  The 
regeneration,  however,  depends  largely  upon  the 
age  and  the  health  of  the  patient.  In  the  very 
young  and  very  old,  and  in  debilitated  or  diseased 
patients,  the  regeneration  of  bone  under  such  con- 
ditions, if  any  at  all,  is  very  feeble. 

THE    RESULT    OF    INFECTION    ON    A    TRANSPLANT. 

The  ultimate  fate  of  a  transplant  in  the  pres- 
ence of  infection  varies  with  the  two  following 
conditions : 

i.  The  time  of  infection  in  relation  to  the 
transplanting;  the  final  results  differ  from  those 
in  which  the  transplant  is  inserted  into  a  bed 
which  has  been  infected  previously,  and  where  the 
bacteria  were  introduced  into  the  transplanted  bed 
at  the  same  time  that  the  osteoblastid  transplant 
was   inserted. 

2.  The  absence  or  presence  of  the  periosteum 
will  modify  the  course  of  invasion  by  the  bacteria, 
and  likewise  the  infection  of  the  marrow  substance 
of  the  transplant.  Then  the  fate  of  the  trans- 
plant depends,  first,  on  the  virulency  of  the  infec- 
tion; second,  on  the  time  of  infection,  whether  it 
is  primary  or  secondary;  third,  on  the  presence  or 
absence  of  the  periosteum;  fourth,  on  the  loca- 
tion of   the   primary   focus. 

The  permanency  of  the  transplant  in  the  pres- 
ence of  infection  is  a  forcible  argument  in  estab- 
lishing the  viability  of  the  bone-graft.  The  fact 
that  a  bone  transplant  reacts  to  an  infection  is  of 
immense  importance   clinically.      It   is   demonstrated 


140  MODERN    OPERATIVE   BONE    SURGERY. 

biologically,  more  effectively  than  histologically, 
that  the  viability  of  the  transplant  is  very  strik- 
ing,  and   is   a   permanent   osseous   entity. 

It  has  been  clearly  demonstrated  that  a  pri- 
mary or  acute  infection  of  the  transplant  bed  is 
more  destructive  to  the  transplanted  osteoplastid 
than  a  chronically  infected  bed;  the  virulence  of 
the  infecting  micro-organism  is  given  as  the 
reason.  Primary  infection,  as  a  rule,  terminates 
in   necrosis   of   the   graft,   with   complete   expulsion. 

Any  portion  of  a  transplant  infected  may 
undergo  sequestration  without  affecting  the  viabil- 
ity of  the  remaining  portion.  A  transplant  in- 
fected which  has  an  established  sinus  does  not 
eventually  affect  the  formation  of  an  excessive  cal- 
lus but  rather  acts  as  a  stimulus  to  osteogenesis, 
with  immobilization  of  the  fragments.  The  peri- 
osteum prevents  the  entrance  of  bacteria,  and  pre- 
vents the  suppurative  process  from  invading  the 
central  part  of  the  graft.  In  mild  infection  it 
should  be  emphasized  that  the  periosteum  and  en- 
dosteum  avert  bacteria  invasion  much  more  read- 
ily, and  maintain  their  vitality  where  compact 
bone  without  the  periosteum  or  endosteum  would 
undergo   necrotic    degeneration    and    absorption. 


CHAPTER  XXL 

Special  Fractures. 

Fractures  of  the  inferior  maxillary  are  far 
more  frequent  than  those  of  any  other  bones  of 
the  face.  The  seat  of  the  fracture  will  be  de- 
termined by  the  force  and  direction  of  the  blow 
causing  the  fracture. 

The  four  most  common  seats  of  fracture  are 
the  body,  the  ramus,  the  alveolar  processes,  and 
the  articulating  processes  or  condyles.  Fractures 
of  this  bone  do  not,  as  a  rule,  require  operative 
treatment.  Satisfactory  alignment  can  usually  be 
maintained  either  by  interdental  splints  or  by  wir- 
ing the  teeth.  The  most  difficult  fracture  of  the 
jaw  to  treat  by  conservative  means  is  fracture  of 
the  ramus,  as  the  interdental  splints  are  incapable 
of  accomplishing  the  desired  results  in  these  cases. 

If  the  fragments  cannot  be  held  in  satisfactory 
alignment,  after  a  reasonable  effort  by  conserva- 
tive means,  or  should  nonunion  result,  operative 
procedures    should  be   resorted  to. 

The  inlay  graft  offers  a  very  efficient  and  sat- 
isfactory agent  for  the  fixation  of  this  group  of 
cases.  The  graft  may  be  obtained  either  from 
the  tibia  or  from  a  rib,  leaving  the  inner  half  of 
the  rib  intact.  The  reason  that  the  rib  offers 
such  an  excellent  graft  is  on  account  of  its  con- 
tour,   or    curved    condition,    which    is    applicable    to 

(141) 


142  MODERN    OPERATIVE   BONE    SURGERY. 

the  jaw.  The  inlay  graft  is  placed  in  a  bed  pre- 
viously prepared  in  the  lower  portion  of  the  frag- 
ments, enough  of  the  outer  surface  of  the  frag- 
ments being  removed  to  receive  the  inlay,  so  that 
the  outer  surface  of  the  inlay  will  be  flush  with 
the  outer   surface  of  the   fragments. 

The  bone-graft's  most  important  mission  in 
this  type  of  case  is  its  germ-resisting  properties. 
It  is  always  advisable  to  wire  the  teeth  in  addi- 
tion to  the  fixation  given  by  the  graft,  wiring  the 
teeth  of  the  lower  jaw  to  the  corresponding  ones 
of  the  upper  jaw.  The  same  postoperative  dress- 
ing is  required  in  these  cases  as  if  treated  by  the 
ordinary  method.  It  is  of  great  importance  that 
the  patient  keep  the  mouth  as  clean  as  possible, 
and  should  be  instructed  to  live  on  liquid  diet 
until  bony  union  takes  place.  The  wound  is 
closed  layer  by  layer,  with  absorbable  material;  the 
skin  is  closed  by  subcuticular  stitch,  plain  catgut 
being  used,  over  which  the  usual  surgical  dress- 
ing is  applied. 


CHAPTER  XXII. 

Fracture  of  the  Clavicle. 

Fracture  of  the  clavicle  is  one  of  the  most 
common  fractures  of  the  bones  of  the  body.  The 
fracture  may  be  partial  or  complete,  single  or 
multiple,  simple  or  compound.  Incomplete  frac- 
tures occur  in  children  which  often  escape  recog- 
nition until   a   callus   has  begun  to  form. 


Fig.  63. — Cross-section  of  clavicle,  illustrating  the  author's 
method  of  making  use  of  an  inlay  graft  removed  from  the 
fragments  of  clavicle,  and  held  in  position  by  bone-pegs  or 
Kangaroo  tendon.  The  graft  is  removed  from  the  anterior  and 
upper  portion  of  clavicle. 

About  one-half  of  all  the  fractures  of  the 
clavicle  occur  in  the  middle  third ;  a  majority  of  the 
remaining  half  occur  near  the  outer  end.  As  a 
rule,  a  recent  simple  fracture  of  the  clavicle  can 
be  satisfactorily  reduced  and  held  in  position  by 
external  methods.  However,  instances  do  occur 
where,  on  account  of  the  obliquity  of  the  fracture, 
or    some    other    cause,    the    fractured    ends    of    the 

(143) 


144  MODERN    OPERATIVE    BONE    SURGERY. 

bone  cannot  be  reduced  or  held  in  position  after 
being  reduced.  Under  such  conditions  a  thin 
autogenous  dowel  or  inlay  graft  should  be  used 
(Fig.  63). 

The  incision  is  made  through  the  skin  V2"  be- 
low and  parallel  with  the  bone.  This  position  of 
the  incision  is  chosen  because  it  is  not  desirable 
to  have  the  incision  directly  over  the  bone,  on 
account  of  the  bone  being  so  superficial,  and  also 
because  it  is  not  good  surgery  to  place  sutures 
of  the  skin  directly  over  a  bone  transplant,  so 
near  the   surface,   on  account  of  possible   infection. 

The  intramedullary  dowel  is  very  easily  ap- 
plied if  it  is  not  made  too  long.  A  peg  %"  to 
%"  in  thickness,  and  1-/2"  in  length,  can  be  easily 
applied,  if  a  hole  i%"  deep  is  made  in  the  end  of 
one  of  the  fragments.  The  hole  must  be  made 
with  a  drill  the  size  of  the  peg  or  dowel  to  be 
used,  in  order  to  easily  insert  the  dowel.  A  %"- 
notch  in  the  opposite  fragment  must  be  made,  and 
the  center  hole  should  extend  V2"  deeper  than  the 
notch.  The  peg  is  first  placed  in  the  fragment 
with  the  I-/4"  hole;  then  the  free  end  of  the 
graft  is  passed  through  the  notch  into  the  hole 
in  the  opposite  fragment.  The  peg  is  divided 
equally  in  the  two  fragments.  Should  the  outer 
end  of  the  inner  fragment  be  displaced  upward, 
and  the  inner  fragment  be  displaced  downward, 
the  notch  should  be  on  the  anterior  surface  of  the 
clavicle,  and  not  on  the  upper  surface.  By  placing 
the  transplant  in  this  position,  the  displacement  is 
absolutely    controlled.      Should    an    inlay    graft    be 


FRACTURE   OF   THE   CLAVICLE.  145 

used,  the  transplant  can  be  removed  from  one 
end  of  one  of  the  fragments,  and  made  to  fit  in 
the  bed  made  in  the  opposite  fragment,  by  re- 
moval of  the  same  shaped  piece  of  bone  but  half 
the  length.  The  inlay  should  be  V-shaped;  and 
the  short  piece  of  bone  removed  from  one  of  the 
fragments  may  be  used  for  making  pegs  to  fasten 
the  inlay  in  position,  or  placed  in  the  vacancy 
caused  by  removal  of  the  inlay. 


10 


CHAPTER  XXIII. 

Fractures  of  Humerus. 

The  location  and  severity  of  fractures  of  the 
humerus,  as  in  all  fractures  of  the  other  long 
bones  of  the  body,  depend  largely  upon  the 
amount  of  force  causing  such  injury,  whether  it 
be  direct  or  indirect.  The  majority  of  fractures 
of  the  humerus  can  be  treated  successfully  by  the 
external  method,  excepting,  however,  if  fractures 
occur  near  the  shoulder  or  elbow-joint,  which 
should  always  be  treated  by  the  open  method. 
In  a  certain  percentage  of  fractures  of  the  shaft, 
in  order  to  obtain  the  best  possible  results,  opera- 
tive procedures  must  be  resorted  to. 

The  fractures,  then,  of  the  upper  end  of  the 
humerus  most  liable  to  require  operative  treatment 
are  fractures  of  the  anatomical  neck,  usually  oc- 
curring in  old  people;  epiphyseal  separation,  which 
occurs  in  young  people;  fractures  of  the  surgical 
neck,  which  most  usually  occur  in  middle  life. 
The  above  fractures  may  occur  with  or  without 
dislocation  of  the  head  of  the  humerus  (Figs.  64 
and  65). 

The  prognosis  in  the  above  fractures,  when 
treated  expectantly,  or  by  the  external  method,  is 
unfavorable,  so  far  as  restoration  of  complete 
function  of  the  shoulder  is  concerned,  for  in  such 
cases  it  is  almost  impossible  to  get  perfect  reduc- 
(146) 


FRACTURES    OF   HUMERUS. 


147 


Fig.  64.— Fracture  of  neck  of  humerus  with  considerable 
deformity.  Six  months  after  accident.  Impaired  motion  of 
arm.     (/.  B.  Murphy.) 


148 


MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  65. — Fracture  of  the  neck  of  humerus,  showing  8-penny 
nail  driven  through  distal  fragment  into  head,  with  perfect  re- 
sult following.     (/.  B.  Murphy.) 


FRACTURES    OF   HUMERUS.  149 

tion,  especially  when  complicated  with  dislocation; 
and  by  not  procuring"  perfect  reduction  and  nor- 
mal anatomical  relations,  excessive  callus  forma- 
tion follows.  If  conditions  permit,  the  operation 
for  autoplastic  repair  in  all  cases  should  be  done 
immediately  after  the  injury,  or  as  soon  thereafter 
as  possible  as  a  primary  reduction  procedure;  if 
the  surroundings  and  conditions  will  not  permit  of 


Fig.  66. — Showing  Langenbeck's  incision,  giving  the  best 
access  to  the  head  of  the  humerus  and  shoulder-joint.  Used  in 
all  operations  on  the  upper  end  of  the  humerus  down  to  the 
insertion  of  the  deltoid  muscle. 

immediate  operation,  the  operation  should  be  de- 
ferred until  after  the  subsidence  of  all  the  acute 
symptoms   of   traumatism. 

The  incision  that  gives  the  best  access  to  the 
shoulder- joint  or  seat  of  fracture,  with  the  least 
disturbance  to  the  surrounding  tissues,  is  that  of 
Langenbeck,  which  is  as  follows   (Fig.  66) : 

An  incision  is  made  from  the  acromial  process, 
down  through  the  middle  of  the  deltoid  muscle  to 


150  MODERN    OPERATIVE   BONE    SURGERY. 

its  insertion,  not  cutting  through  the  fibers  of  the 
muscle,  but  separating  them  with  a  blunt  instru- 
ment. By  carefully  retracting  the  muscle,  it  gives 
free  access  to  the  fractured  fragments.  Great 
caution  must  be  exercised  in  avoiding  the  circum- 
flex nerve,  as  injury  to  it  would  destroy  some  of 
the  movements  of  the  arm  by  causing  paralysis 
and   atrophy  of  the  deltoid  muscle. 

After  the  wound  has  been  carefully  cleansed  of 
blood-clots,  exudates,  and  detached  fragments  of 
bone,  the  character  of  the  fracture  can  be  easily 
determined,  and  the  kind,  length,  and  size  of  the 
transplant  required  to  support  the  fragments,  and 
hold  them  in  perfect  anatomical  relation,  decided 
upon. 

The  best  material  for  transplantation  in  these 
fractures  is  secured  from  the  shaft  of  the  hum- 
erus, from  below  the  fracture,  whether  an  inlay 
or  intramedullary  dowel  is  used  (as  shown  in 
Fig.  67).  The  exact  measurement  of  the  length 
and  width  of  the  transplant  is  determined  by  the 
use  of  the  author's  caliper  knives.  Great  caution 
must  be  exercised  to  prevent  injuring  the  mus- 
culospiral  nerve.  If  an  intramedullary  dowel  is 
used,  the  periosteum  should  be  removed  from 
the  transplant  at  its  source;  if  the  inlay  graft  is 
used,  the  periosteum  should  always  be  left  on  the 
graft. 

The  dowel  should  be  rectangular,  so  that  when 
it  fits  into  the  ends  of  the  fragments  the  corners 
will  impinge  and  prevent  rotation  of  the  head, 
without  rotation  of  the  shaft  of  the  bone;  in  other 


FRACTURES    OF   HUMERUS. 


151 


words,    it    prevents    any    abnormal    motion    of    the 
head  after  the  dowel  is  once  placed  in  position.    A 


Fig.  67. — Fracture  of  the  surgical  neck  of  the  humerus, 
showing  parallel  saws  being  used  in  removing  a  sliding  inlay 
graft  from  distal  fragment,  making  bed  in  proximal  end  for 
its  reception. 

round  spike-transplant  would  permit  rotation  be- 
tween the  head  and  shaft,  which  would  be  un- 
desirable   (Fig.   68). 


Fig.  68. — Showing  the  use  of  the  round  bone-peg  for  hold- 
ing in  position  an  oblique  fracture  of  the  surgical  neck  of  the 
humerus. 


152  MODERN    OPERATIVE   BOXE    SURGERY. 

After  having  used  the  author's  %"  motor  drill 
to  make  a  hole  in  the  lower  fragment,  1V2"  in 
depth,  or  whatever  the  desired  depth  may  be.  if 
the  transplant  is  to  be  1o//  square,  an  ordinary 
carpenter's  chisel  *4"  wide  would  be  used  to 
square  the  hole ;  then  proceed  with  the  upper  fragment 
in  the  same  manner,  first  using  the  drill,  and  after 
the  drill  using  the  chisel  to  square  the  hole. 
While  preparing  the  fragments  the  extension  must 
be  released.  If  the  fracture  is  in  the  anatomical 
neck,  in  squaring  the  hole  you  should  be  careful 
not  to  cut  through  the  cartilage  covering  the  head 
of  the  bone,  but  just  cut  to  the  cartilage.  After 
having  prepared  the  ends  of  the  fragments  for  the 
reception  of  the  transplant  or  dowel,  now  proceed 
to  remove  the  graft  from  whatever  location  has 
been  decided.  The  graft  is  removed,  and  is  now 
ready    for    insertion. 

As  previously  stated,  if  a  dowel  is  used,  the 
periosteum  must  always  be  removed.  If  the  ordinary 
method  is  used  the  transplant  is  first  accurately 
fitted  to  the  lower  fragment.  It  is  now  removed 
from  the  lower  fragment,  and  placed  in  the  upper 
fragment.  In  preparing  the  bed  or  hole  in  the 
upper  fragment,  great  caution  must  be  used  to 
prepare  it,  so  that  when  the  dowel  is  inserted  in 
the  final  position  in  the  upper  and  lower  frag- 
ments perfect  anatomical  relation  will  exist  be- 
tween the  shaft  and  head.  The  exact  rotation- 
alignment  of  fragments  can  be  determined  either 
b}^  the  irregularities  of  the  fracture  or  by  the 
known  anatomical  relations  of  the  head  of  the 
humerus   to   the   shaft. 


FRACTURES    OF   HUMERUS. 


153 


Fig.  69. — Fracture  of  anatomical  head  of  humerus,  showing 
ordinary  displacement  of  such  fracture. 


154  MODERN    OPERATIVE   BONE    SURGERY. 


Fig.  70. — Same  as  Fig.  69,  after  application  of  rectangular 
intramedullary  dowel,  which  holds  fragments  in  perfect  ana- 
tomical relation,  and  prevents  them  from  rotating  upon  each 
other. 


FRACTURES    OF   HUMERUS. 


155 


The  head  of  the  bone  being  in  correct  rotation 
with  the  shaft,  the  transplant  is  placed  snugly  into 
the  canal  of  the  lower  fragment,  after  which  the 
free  end  is  placed  into  the  upper  fragment  or 
head  by  the  lower  fragment  being  bent  at  an 
angle,  and  extended  and  manipulated  until  the 
free  or  upper  end  of  the  transplant  can  be  made 
to  enter  and  rest  firmly  in  the  squared  opening 
in  the  upper   fragment  prepared   for   its   reception. 


Fig.  71. — Illustrates  the  use  of  the  rectangular  dowel  in  fracture 
of  the  anatomical  neck  of  the  humerus. 


Before  closing  the  wound,  while  the  repaired  frag- 
ments are  still  in  full  view,  the  arm  is  firmly 
fastened  to  the  side  of  the  chest  with  adhesive 
plaster  applied  to  the  lower  portion  of  the  arm. 
Before  fastening  the  arm  to  the  chest  with  ad- 
hesive plaster  it  is  well  to  place  between  the  arm 
and  chest  three  or  four  thicknesses  of  some  soft 
material   to   prevent   excoriation. 

The  wound  is  closed,  layer  by  layer,  with  ab- 
sorbable material,  and  dressed  with  plain  gauze. 
The  forearm  is  placed  at  about  a  45-degree  angle 
with     the    arm.       A    crenolin    or    plaster-of-Paris 


156  MODERN    OPERATIVE   BONE    SURGERY. 

dressing  is  now  applied,  completely  enveloping  the 
shoulder,  arm,  and  forearm.  The  fixed  dressing  is 
removed  in  four  weeks,  and  passive  motion  is 
made  of  the  arm.  If  the  transplant  has  been  ac- 
curately applied,  with  proper  attention  given  to 
the  mechanical  condition  of  the  individual  fracture, 
the  head  of  the  humerus  presenting  its  normal  re- 
lations to  the  joint,  the  arm  completely  immob- 
ilized during  the  time  required  for  bony  union  to 
take  place,  the  callus  formation  will  be  small,  and 
will  not  interfere  with  motion  of  the  arm.  If  the 
technic  has  been  perfect,  early  and  complete  res- 
toration of  the  function  of  the  shoulder- joint  will 
follow. 

Should  any  of  the  above  details  be  slighted  or 
poorly  executed  during  the  application  of  the 
autogenous  intramedullary  dowel  for  the  repair  of 
this  class  of  fractures,  the  results  will  be  equal 
to   the   efforts   made. 

All  fractures  occurring  above  the  insertion  of 
the  pectoralis  major  and  the  teres  major  muscles 
and  below  the  epiphyseal  line  are  considered  frac- 
tures of  the  surgical  neck  of  the  humerus.  After 
a  fair  attempt  has  been  made  properly  to  reduce 
and  hold  the  fragments  in  proper  anatomical 
alignment  and  rotation,  and  such  attempt  has 
failed,  which  frequently  does  occur,  the  surgeon  is 
justified  in  proceeding  at  once  to  prepare  the 
patient  for   open  treatment  of   such   fracture. 

After  careful  and  thorough  preparation  of  the 
patient,  Langenbeck's  incision  prolonged  downward 
is   used    to    expose    the    fracture.      After    exposing 


FRACTURES    OF   HUMERUS. 


157 


Fig.  72. — Fracture  of  head  of  humerus,  with  two  8-penny 
fence  nails  driven  through  distal  fragment  into  head  of  bone. 
A  perfect  result  followed.     (/.  B.  Murphy.) 


158 


MODERN    OPERATIVE   BONE    SURGERY, 


the  fractured  ends  of  the  bone,  the  debris  caused 
by  the  injury  is  removed  from  around  the  frag- 
ments. Caution  is  used  to  protect  the  nerves  and 
vessels  in  close  proximity  to  the  fragments  during 
the  manipulation  of  the  fractured  ends  of  the 
bone.  The  best  material  for  this  autogenous  trans- 
plant  is   removed   from   the   shaft   of   the   humerus, 


Fig.  73. — Illustrates  the  author's  method  of  removing  graft 
(A)  from  the  distal  fragment  (B)  and  forcing  it  down  into 
the  medullary  cavity,  up  into  position  (C),  dividing  the  rect- 
angular dowel  equally  between  the  fractured  ends  of  the  bone 
(B  and!?). 

or  from  whatever  bone  fractured,  i1/^"  to  21/-Vf  below 
or  above  the  fracture,  whichever  is  most  feasible. 
In  fracture  of  the  humerus  the  graft  should  be 
about  y2"  wide,  and  2"  to  3"  in  length.  After 
the  ends  of  the  fragments  have  been  prepared  for 
the  reception  of  the  graft,  the  graft  is  forced  into 
the  medullary  canal,  then  up  through  the  upper 
end  of  the  lower  fragment  into  the  lower  end  of 
the  upper  fragment  (as  shown  in  Fig.  y^)  or 
vice  versa.     If  done  in  the  old  method  the  graft  is 


FRACTURES    OF    HUMERUS.  159 

first  fitted  into  the  lower  fragment,  then  removed 
and  fitted  into  the  upper  fragment;  the  lower  bed 
is  always  made  a  little  bit  longer  or  deeper,  so 
that  the  graft  may  be  pushed  into  said  fragment, 
in  order  to  get  it  into  the  upper  fragment.  After 
engaging  in  the  upper  fragment,  a  sharp  instru- 
ment is  used  to  equalize  the  graft  between  the 
two  fragments.  The  transplant  must  not  cross 
the  epiphyseal  line  in  a  growing  bone,  as  it  will 
interfere  with  the  continuation  of  the  growth  of 
the  bone  by  causing  ossification  between  the  epi- 
physes and  diaphysis.  The  graft  in  position,  if 
the  technic  and  mechanical  details  of  the  opera- 
tion have  been  thoroughly  executed,  the  muscles 
will  contract  and  hold  the  fragments  in  normal 
position   and   alignment. 

The  transplant  prevents  the  rotation  of  one 
fragment  on  the  other.  While  the  wound  is  open, 
and  the  fractured  ends  of  the  bone  are  still  in 
view  of  the  operator,  the  arm  is  securely  fastened 
to  the  chest  by  adhesive  plaster.  The  wound  is 
now  closed,  layer  by  layer,  with  some  absorbable 
suture.  A  subcuticular  stitch  is  used  to  close  the 
skin,    and    it    is    dressed   in    the   usual    way. 

In  fracture  of  the  shaft  of  the  humerus, 
where  we  have  overriding  or  a  displacement  that 
cannot  be  reduced  by  traction  and  manipulation, 
open  reduction  should  at  once  be  resorted  to. 
After  reducing  the  fragments  to  perfect  ana- 
tomical relations,  if  the  fragments  can  be  held  in 
position  without  an  inlay  or  intramedullary  dowel,  it 
would  not  be   good   surgery  to   proceed  to   use   the 


160 


MODERN    OPERATIVE   BONE    SURGERY. 


autogenous   graft   in   such   case.      However,    should 
the    surgeon    be    unable    to    hold    such    fracture    in 


Fig.  74. — A,  fracture  of  humerus  near  middle  of  lower  third, 
of  three  months  standing,  showing  considerable  callus  forma- 
tion around  ends  of  both  fragments,  with  some  bony  union  be- 
tween fragments.  Bad  deformity.  B,  three  months  after  ap- 
plication of  intramedullary  dowel,  with  good  alignment  and 
bony  union. 


normal  position  without  the  autogenous  intrame- 
dullary dowel  or  inlay  graft,  he  should  proceed  to 
prepare    the    fractured    ends    of    the    bone    for    the 


FRACTURES    OF   HUMERUS. 


161 


reception  of  the  inlay  graft  or  intramedullary 
dowel  (Fig.  75),  whichever  he  thinks  best  to  use 
The  inlay   or    dowel    should   be   removed    from   the 


Fig.  75. — Illustrating  fracture  of  humerus  after  fragments 
have  been  placed  in  position  and  intramedullary  dowel  applied. 
Two  months  after  application  of  dowel,  with  fairly  good  bony 
union. 


shaft  of  the  fractured  bone;  if  not  from  the  frac- 
tured bone,  it  may  be  taken  from  the  tibia  or 
fibula. 

After    the    fragments    have  been    prepared    for 

the  reception  of  the  graft,  and  the  graft  has  been 


11 


162 


MODERN    OPERATIVE   BONE    SURGERY. 


removed    from    the    chosen    part,    the    manner    of 

placing    it    in    position    would    be    the    same    as    in 

Any   oversized   or 
a  "  B 


fractures   of   the   surgical   neck 


Fig.  76. — A,  fracture  of  humerus  near  middle  of  middle 
third,  showing  piece  of  bone  broken  entirely  loose  from  both 
fractured  ends  of  the  bone.  This  fracture  could  not  be  success- 
fully treated  by  the  closed  method.  B,  two  weeks  after  rect- 
angular intramedullary  dowel  had  been  applied,  showing  loose 
bone  in  perfect  condition,  and  fragment  ends  in  perfect  ana- 
tomical relation  and  alignment.    An  ideal  result  followed. 

ill-fitting  transplant  must  not  be  driven  into  the 
medullary  canal  of  any  fractured  bone,  because  it 
will   cause  pressure-necrosis  at   the  point   of  forced 


FRACTURES    OF   HUMERUS.  163 

contact.  The  ill-fitting  graft  may  also  split  the 
fragment  into  which  it  is  driven.  In  case  the 
bone  is  split  by  forcing  an  ill-fitting  transplant 
into   its   medullary   canal   or  by  accidental   force,   a 


Fig.  77. — Transverse  fracture  of  the  humerus  near  junction 
of  the  middle  with  lower  third,  showing  intramedullary  dowel 
in  position.    Perfect  result  followed. 

kangaroo  tendon  should  be  wrapped  two  or  three 
times  around  and  drawn  tightly  to  bind  the  frag- 
ments together.  A  loose-fitting  transplant  is  just 
as  bad  as  one  that  is  too  tight.  Actual  contact 
of  the   entire  graft  to   the   recipient  bone  is  neces- 


164 


MODERN    OPERATIVE   BONE    SURGERY. 


sary  for  continued  success.  The  wound  is  sutured 
in  the  same  manner  as  fractures  of  the  surgical 
and  anatomical  neck.  In  fractures  of  the  shaft, 
a  well-fitting  plaster-of-Paris  dressing  should  also 
be  applied;  the  cast  should  extend  up  over  the 
shoulder;  the  arm  should  be  bound  to  the  body- 
to  prevent  changes  in  alignment  or  any  motion  be- 
tween the  graft  and  the  host.  As  a  rule,  at  the 
end   of   four   weeks   the   arm   should   be   re-dressed. 


Fig.  78. — Fracture  of  lower  end  of  humerus  with 
deformity.     (/.  B.  Murphy.) 

The  bony  union  with  palpable  callus  is  perceptible, 
and  a  straight  and  good  functional  arm  is  the 
result  of  a  carefully  applied  autogenous  bone- 
graft.  The  limb,  however,  should  not  be  exten- 
sively used  for  at  least  three  or  four  weeks 
longer. 

In  supracondylar  fractures  of  the  humerus 
(Fig.  78),  which  are  in  such  close  proximity  to 
the   joints    that,    unless    we   have   perfect   reduction 


FRACTURES    OF   HUMERUS. 


165 


of  the  fragments  to  normal,  there  is  liable  to  be 
a  callus  formation,  which  in  some  cases  does  in- 
terfere with  the  motion  of  the  joint.  As  a  rule, 
these    fractures     can    be    held    in    position     (after 


Fig.  78a. — Same  as  Fig.  78,  giving  a  different  view.  Illus- 
trating fragments  held  together  with  an  ordinary  8-penny 
finishing  nail  driven  through  proximal  ends  of  distal  fragments 

and  distal  ends  of  proximal  fragments.     (/.  B.  Murphy.) 

being  properly  reduced)  by  the  external  method. 
If,  however,  the  surgeon  in  charge  should  not  be 
able  to  hold  the  fragments  in  proper  position,  the 
open  method  should  be   resorted  to. 

A   free    incision    is    made    on    the   outer    surface 


166  MODERN"    OPERATIVE    BOXE    SURGERY. 

of  the  arm.  An  intramedullary  dowel  is  intro- 
duced in  the  same  manner  as  in  fracture  of  the 
shaft  of  the  bone.  The  closing  of  the  wound  and 
fixed  dressing  are  also  used  the  same  as  in  frac- 
tures  of   the    shaft. 

In  fractures  of  the  internal  and  external  con- 
dyles of  the  humerus,  if  there  is  much  swelling, 
it  is  not  an  easy  task  to  make  a  diagnosis  with- 
out the  X-ray.  As  previously  stated,  however,  the 
X-ray  should  be  resorted  to  in  all  fractures.  After 
completing  the  diagnosis,  and  a  fair  effort  having 
been  made  to  reduce  and  immobilize  the  broken 
condyles,  and  the  condylar  fragment  is  still  so  dis- 
placed that  the  articulation  is  abnormal,  it  is  es- 
sential that  an  open  reduction  and  fixation  of  the 
fragments  in  their  normal  position  by  a  dowel 
transplant   be  made   at   once. 

After  placing  the  condyle  in  position  the 
author's  %e"  motor  drill  is  used  to  make  a  hole, 
starting  at  the  most  prominent  part  of  the  con- 
dyle. If  it  is  the  inner  condyle,  the  drill  should 
pass  upward  and  outward,  passing  just  above  the 
olecranon  fossa  and  through  the  compact  bone, 
above  and  inside  of  the  depression.  It  is  neces- 
sary that  the  peg  in  such  cases  should  fit  very 
snugly.  If  the  external  condyle,  the  same  size 
drill  is  used,  and  the  hole  is  made  at  the  same 
angle.  For  the  internal  condyle,  the  incision  is 
made  directly  over  the  most  prominent  part,  and 
extends  2"  or  3"  up  the  arm,  which  gives  good 
access  to  the  seat  of  fracture.  Care  must  be 
exercised  not  to  injure  the  ulnar  nerve. 


FRACTURES    OF   HUMERUS. 


167 


If  the  external  condyle  is  fractured,  a  free  in- 
cision is  made  over  the  outer  and  most  prominent 
part,  and  care  must  be  exercised  not  to  injure  the 
tissue  in  or  around  the  joint.  After  the  applica- 
tion of  the  autogenous  peg",  the  wound  is  closed 
in  layers  with  absorbable  material.  Gauze  is  ap- 
plied   to   the   wound,    and    the    arm    is   placed    in    a 


Fig.  79. — T-f  racture  with  two  10-penny  finishing  nails ;  one 
driven  through  external  condyle  up  into  shaft,  the  other 
through  internal  condyle,  the  nails  meeting  at  right  angle,  into 
shaft.     (/.  B.  Murphy.) 


plaster-of-Paris    cast,    with    the    forearm    flexed    at 
right  angle   to  the   arm. 

In  T-f  racture  ( Fig.  79 ) ,  or  a  fracture  of  both 
condyles  into  the  elbow-joint,  the  condyles  can  be 
secured  by  two  peg  transplants  driven  into  the 
shaft,  one  peg  anterior  to  the  other,  above  and 
below  the  line  of  fracture.  A  plaster-of-Paris 
dressing  is  applied,  with  the  forearm  at  right  angle 
with  the   arm,   after   the   wound   has   been   closed. 


CHAPTER  XXIV. 

Fractures  of  the  Forearm. 

Fractures  of  the  olecranon  process  are  the  re- 
sult of  direct  violence  in  a  majority  of  cases. 
Cases    have    been    recorded    that  violent  contraction 


Fig.  80. — Fracture  of  the  olecranon.     (/.  B.  Murphy.) 

of  the  triceps  muscle  has  caused  such  fracture, 
but  it  is  very  uncommon.  The  line  of  frac- 
ture is  usually  transverse,  and  passes  through 
the  middle  or  base  of  the  process.  It  may  be 
simple  or  compound.  There  is  always  a  consider- 
able amount  of  contusion  and  swelling  of  the 
overlying  soft  parts,  and  the  joint  is  filled  with 
blood.  In  some  cases  it  is  almost  impossible  to 
make  a  diagnosis  of  the  fracture  without  the  use 
of  the  X-ray,  on  account  of  the  extensive  swell- 
ing. The  X-ray  should  be  used  in  all  cases, 
(168) 


FRACTURES  OF  THE  FOREARM. 


169 


whether    swelling    exists    or    not,  because  the  rays 
show    the    exact    condition    and    position    of    the 


fragments. 


If  treated  by  the  external  method,  fibrous 
union,  as  a  rule,  follows.  In  the  majority  of 
cases  it  matters  not  how  perfect  the  apposition 
of  the   fragments   may  be,   it   is   almost   impossible 


Fig.  81. — Showing  10-penny  finishing  nail  driven  through 
olecranon  process  into  shaft  of  ulna.   (/.  B.  Murphy.) 


to  get  bony  union  without  the  use  of  the  autog- 
enous bone-graft;  so  it  is  the  duty  of  the  surgeon 
in  all  fractures  of  the  olecranon  process  to  pro- 
ceed at  once,  or  at  the  soonest  possible  time  that 
the  patient  can  be  gotten  into  the  proper  condi- 
tion to  be  operated  upon,  to  adopt  the  open 
method,  and  apply  a  well-fitting  autogenous  bone- 
graft. 


170 


MODERN    OPERATIVE   BONE    SURGERY. 


If  an  inlay  graft  is  used  (Fig.  82)  the  graft 
can  be  obtained  from  the  shaft  of  the  ulna,  and 
can  be  retained  in  position  by  kangaroo  tendon 
or   bone-peg. 

Should  it  be  decided  to  use  an  intramedullary 
dowel,  the  graft  can  be  removed  from  the  shaft 
of  the  ulna  or  tibia.  The  graft  should  be  at  least 
^4"   to    %"    in   diameter    (Fig.    13). 


Fig.  82. — Shows  the  sliding  inlay  graft  removed  from  the 
distal  fragments  of  fractured  end  of  olecranon  process.  Bone- 
peg  made  from  proximal  or  short  fragment.  Also  shows 
method  of  driving  in  bone-pegs  to  hold  fragments  firmly  in 
position. 

In  ununited  fractures  of  this  process,  the 
bone-graft  must  extend  at  least  Y^ff  beyond  the 
eburnated  area  in  the  healthy  bone.  Should  the 
graft  not  extend  beyond  the  sclerosed  area  it 
would   fail   in    its   purpose. 

Special  attention  must  be  paid  to  the  accurate 
fitting  of  the  graft  in  this  fracture,  for  the  de- 
mands upon  the  graft  are  distinctly  twofold:  (1) 
to  stimulate  the  growth  of  the  bone  by  the  osteo- 


FRACTURES  OF  THE  FOREARM.         171 

genetic  properties;    (2)    to  retain  the  fragments   in 
perfect    position. 

After  closing  and  dressing  the  wound  in  the 
usual  manner,  the  arm  is  dressed  in  the  extended 
position,  and  a  well-fitting  plaster-of-Paris  dressing 
is  applied,  which  is  allowed  to  remain  on  the  arm 
from  four  to  five  weeks.  On  removal  of  the 
dressing,  passive  motion  is  made.  Vigorous  use 
of  the  arm  should  not  be  permitted  for  six  weeks 
to  two  months  after  the  accident. 

Fracture  of  the  coronoid  process,  although 
rarely  occurring,  is  much  more  frequent  than  was 
formerlv  thought.  Fractures  of  this  portion  of 
the  upper  end  of  the  ulna  occur  more  frequently 
in  connection  with  backward  dislocation  of  the 
bones  of  the  forearm  at  the  elbow  than  otherwise. 
When  complicated  with  dislocation,  there  is  a  tend- 
ency for  the  bone  to  slip  backward  again  after 
reduction. 

A\  nen  fracture  of  the  coronoid  process  occurs 
as  an  isolated  injury,  it  is  almost  always  the  re- 
sult of  indirect  violence,  usually  from  falling  upon 
the  outstretched  hand. 

Diagnosis,  as  a  rule,  can  be  made  in  these 
cases  without  the  aid  of  the  X-ray- 
Whenever  it  is  impossible  to  hold  the  fragment 
in  proper  position  by  the  external  method,  a  care- 
ful dissection  is  made,  avoiding  the  blood-vessels 
and  nerves,  exposing  the  fragment,  which  is  placed 
in  position,  after  which  a  %&"  drill  is  used  to 
make  a  hole  through  the  fragment  into  the  bone, 
the     hole     pointing     forward     and     downward.       A 


172 


MODERN    OPERATIVE   BONE    SURGERY. 


snugly  fitting  peg  is  now  driven  in,  which  will 
hold  the  fragment  in  perfect  position,  and  the 
wound  is  closed  in  the  usual  manner,  and  covered 
with    sterile    gauze.      The    forearm    is    flexed    at    a 


Fig.  83. — A,  fracture  of  radius,  with  a  space  of  H_mch  be- 
tween fragments  due  to  crushing  of  the  bone.  B,  showing  in- 
tramedullary dowel  in  position.  Two  months  after  operation, 
with  good  bony  union  following. 


45°  or  500  angle  with  the  arm,  and  then  the 
arm  and  forearm  are  put  up  in  a  plaster-of-Paris 
dressing.  The  dressing  is  allowed  to  remain  on 
from  four  to  six  weeks. 


FRACTURES  OF  THE  FOREARM. 


173 


Fig.  84. — Fracture  of  ulna  near  the  junction  of  the  middle 
with  the  lower  third,  with  displacement,  which  as  a  rule  is  im- 
possible to  reduce  by  the  closed  method. 


174  MODERN    OPERATIVE   BOXE    SURGERY. 

Fractures  of  the  neck  of  the  radius,  formerly 
thought  to  be  rare,  are  of  frequent  occurrence. 
The  usual  cause  is  falling"  upon  the  hand,  with 
the  elbow  extended.  Fractures  of  the  neck  are, 
as  a  rule,  associated  with  those  of  the  head,  and 
are  frequently  impacted.  The  line  of  the  fracture 
of  the  neck  usually  is  transverse  or  oblique,  unless 
it  is  a  continuation  of  a  fracture  of  the  head.  As 
a  rule,  perfect  anatomical  relations  can  be  main- 
tained by  the  external  method.  After  a  fair  at- 
tempt has  been  made,  and  it  is  found  impossible 
to  hold  the  fragment  in  position,  the  surgeon 
should  proceed  at  once  to  treat  it  by  the  open 
method  using  an  autogenous  peg,  extending 
through  the  head  into  the  shaft.  Should  the  head 
be  broken,  or  split  in  two,  a  kangaroo  tendon  of 
large  size  is  placed  a  couple  of  times  around  the 
head,  and  bound  tightly,  to  hold  the  fragments 
together.  The  wound  is  closed  as  usual,  and  the 
forearm  is  flexed  at  a  little  more  than  right  angle 
with  the  arm,  midway  between  pronation  and 
supination,  and  placed  in  a  plaster-of-Paris  dress- 
ing. The  dressing  is  removed  from  four  to  six 
weeks  after  it  has  been  applied,  and  passive 
motion    is   made,    with    moderate   massage. 

Fractures  of  the  shaft  of  the  ulna  and  radius 
may  occur  together,  or  either  bone  may  be  broken 
separately  (Fig.  84).  The  most  common  seats  of 
fracture  are  in  either  the  middle  or  lower  third 
of  the  long  bones.  The  radius  is  often  fractured 
a  little  higher  up  than  the  ulna.  Fractures  of  the 
shaft   of   the   ulna   usually   occur   because   of   a   di- 


.  FRACTURES  OF  THE  FOREARM.         1/5 

rect  blow  received  upon  the  arm,  raised  for  pro- 
tection. It  is  not  as  common  as  fracture  of  the 
radius.  Fracture  of  the  radius  may  occur  at  any 
part  of  the  shaft;  displacement  varies  with  the 
location  of  the  fracture. 

As  a  rule,  diagnosis  of  either  fracture  of  the 
radius  or  ulna  can  be  made  without  any  difficultv, 
unless  great  swelling  should  exist;  Under  such 
conditions,  the  X-ray  should  be  used  before  and 
after  attempts  of  reduction.  After  a  reasonable 
effort  has  been  made  to  reduce  the  fragments  to 
proper  relation,  without  success,  the  surgeon  is 
justified  in  proceeding  to  treat  the  dissolution  of 
such  bone  by  the  open  method.  If,  after  exposing 
the  fragments,  he  finds,  as  is  usual,  muscles  or  other 
soft  tissues  have  prevented  the  reduction  of  the 
parts  to  perfect  alignment  by  the  external  method 
(manipulation,  etc.),  and  if  after  placing  the  ends 
of  the  bone  in  perfect  anatomical  relation,  they 
will  remain  so  without  any  further  procedure,  the 
wound  should  be  closed  and  dressed,  and  treated 
as  a  simple  fracture.  But  if  the  bones  will  not 
remain  in  position,  the  autogenous  bone-graft 
should  be  applied,  and  the  inlay  graft  is  well 
chosen  in  fractures  of  the  ulna  or  radius,  for 
all  that  is  necessary  in  such  fractures  is  to  hold 
the  fragments  in  apposition,  which  it  does  to  a 
nicety,  except  when  both  bones  are  broken,  then 
the  dowel  should  be  used,  for  it  gives  better 
fixation. 

The  autogenous  graft  used  in  these  fractures 
should    be    removed    from    the    fragment    above    or 


176  MODERN    OPERATIVE   BONE    SURGERY. 

below  the  fracture  or  from  the  upper  third  of  the 
tibia  shaft,  from  the  upper  end  of  the  shaft  of 
the  tibia,  because  the  compact  bone  there  is  not 
so  thick  as  in  the  lower  portion  of  the  shaft.  The 
dowel  should  not  be  over  %"  in  diameter.  The 
same  precautions  in  placing  the  dowel  in  these 
fractures  should  be  carried  out  as  in  fractures  for- 
merly detailed.t  The  wound  is  closed  with  ab- 
sorbable material,  layer  by  layer,  and  the  skin  is 
closed  with  plain  catgut,  subcuticular  stitch;  twenty- 
eight  to  thirty  layers  of  gauze  are  snugly  placed 
thereon.  The  forearm  is  placed  at  right  angle 
with  the  arm,  and  a  plaster-of-Paris  dressing  care- 
fully applied,  extending  from  the  finger  tips  to  the 
shoulder. 

Fractures  of  the  lower  end  of  the  radius  and 
ulna  are  quite  common.  All  fractures  within  i" 
of  the  articulating  surface  of  the  radius  are 
classed  as  Colles'  fractures.  The  structure  of  the 
radius  in  its  entire  shaft  is  quite  compact,  but  as 
it  nears  the  wrist- joint,  about  an  inch  above  the 
lower  end,  it  expands  into  a  more  cancellous  and 
less  resistant  bone-tissue.  The  articular  surface  of 
the  radius  possesses  not  only  a  groove  for  the 
ulna,  but  it  articulates  with  all  of  the  first  row  of 
the    carpal   bones. 

Fractures  of  the  lower  end  of  the  radius  con- 
stitute about  10  per  cent,  of  all  fractures  of  the 
bones  of  the  body.  In  typical  fractures  of  the 
lower  end  of  the  radius,  the  line  of  fracture  is 
from  %"  to  %"  above  the  articulating  surface; 
usually  it  is  transverse,  but  it  may  be  oblique,   in 


FRACTURES  OF  THE  FOREARM.        177 

an  anteroposterior  or  lateral  direction.  A  fall 
upon  the  outstretched  and  extended  hand  is  the 
most   frequent   cause. 

In  the  treatment  of  Colles'  fracture,  one  should 
have  a  clear  conception  of  the  usual  displacement 
of  the  fragments,  and  the  resultant  deformity.  It  is 
well  to  remember  that  impaction  of  the  fragments 
is  usually  the  greatest  obstacle  to  perfect  reduc- 
tion of  the  fragments,  by  the  external  method.  As 
in  all  other  fractures,  the  most  important  task  of 
the  surgeon  is  to  correct  the  deformity  by  the 
reduction  of  the  fragments,  and  having  accom- 
plished this,  to  maintain  them  in  perfect  apposi- 
tion, until  firm  bony  union  has  taken  place.  In  a 
great  many  cases,  this  is  not  done  in  Colles'  frac- 
tures, and  the  natural  result  is  that  deformity  of 
the   injured  member   follows. 

After  the  surgeon  has  reduced  or  supposedly 
reduced  the  displaced  fragments,  a  two-position 
X-ray  examination  should  be  made  anteroposterior 
and  lateral.  If  the  X-ray  shows  that  the  frag- 
ments are  not  in  perfect  apposition,  and  they  can- 
not be  so  placed  by  the  external  method,  the  sur- 
geon should  proceed  to  use  the  open  method  of  re- 
duction. After  the  fragments  have  been  placed 
in  perfect  anatomical  relation,  as  a  rule,  it  is  not 
necessary  to  use  the  autogenous  internal  splint. 
All  that  is  necessary  is  to  apply  a  well-fitting  pos- 
terior external  splint,  before  the  wound  has  been 
duly  closed.  However,  should  the  surgeon  deem 
it  wise  to  use  the  internal  splint,  the  autogenous 
peg  is  ideal;  it  should  be  %"  to   %"  in  diameter, 

and    from    1V2"    to    2"    in   length. 

12 


CHAPTER  XXV. 


Fractures  of  the  Femur. 

Fractures  of  the  hip  (Fig.  85),  or  neck  of 
the  femur,  occur  most  frequently  in  elderly  people. 
It  is  by  far  the  most  disabling  of  all  types  of 
fracture.      It   ordinarily   is    associated   with   a   very 


Fig.  85. — Showing  rectangular  clowel-graft  driven  in  posi- 
tion in  fracture  of  neck  of  femur,  which  prevents  rotation  or 
motion  of  head  without  moving  the  entire  limb. 

slight  accident,  such  as  a  misstep,  or  fall  upon 
the  floor,  from  a  standing  position.  Undoubtedly, 
in  many  instances  the  fracture  precedes  the  fall. 
Stimson  states  that  the  strain  exerted  through 
the  ligaments  in  extreme  positions  of  the  limb  is 
a  more  frequent  cause  of  the  fracture  than  is 
generally   supposed. 

Fractures    of    the    femur    usually    occur    beyond 
the    age   of    50.      They    constitute    one-third    of    all 
the    fractures    at    and    after    this    period    of    life. 
(178) 


FRACTURES    OF   THE   FEMUR. 


179 


They  occur  more  frequently  in  women  than  in  men. 
The  chief  reason  for  the  frequency  of  fracture 
of  the  neck  of  the  femur  in  elderly  people  is  the 
atrophy  or  osteoporosis  which  occurs  in  all  parts 
of  the  osseous  system,  and  which  is  more  marked 
at  the  neck  of  the  femur.  The  cortex  becomes 
much  thinner,  and  the  meshes  of  the  cancellous 
tissue  are  greatly  enlarged. 


Fig.  86. — Diagram  illustrating  the  rectangular  dowel  used  in 
fractures  of  the  surgical  neck  of  the  femur.  By  making  hole 
entirely  through  upper  fragment  with  the  author's  right-angle 
arm  motor  drill,  application  of  the  intramedullary  dowel  is 
made  easy. 

There  seems  to  be  no  object  in  classifying 
these  fractures  ariy  further  than  the  single  term, 
"fracture  of  the  neck,"  as  far  as  the  treatment 
and  prognosis  are  concerned.  However,  it  might 
be  well  to  state  that  nonunion  is  more  likely  to 
occur,  and  is  almost  a  rule,  in  fractures  of  the 
junction  of  the  head  and  neck.  This  is  due  to 
the  fact  that  the  periosteum  of  the  neck  may  be 
extensively  torn,  as  the  result  of  the  fracture.     If 


180  MODERN    OPERATIVE    BOXE    SURGERY. 

so,  the  only  source  of  nutrition  for  the  head  is 
then  through  the  ligamentum  teres,  and  but  little, 
if  any,   callus  formation  takes   place. 

Then,  again,  this  fracture  is  rarely  reduced  by 
the  external  method,  because  the  small  fragment 
cannot  be  controlled  and  rarely  held  in  immob- 
ilization for  a  sufficient  length  of  time  for  bony 
union  to  occur,  even  if  reduction  has  been  com- 
pletely accomplished.  In  unimpacted  fractures  of 
any  portion  of  the  neck,  when  treated  by  external 
method,  the  prognosis  is  bad.  As  a  rule,  fibrous 
union  takes  place,  and  the  functional  end  results 
are  not  good.  It  is  hard  to  appreciate  how  un- 
satisfactory these  results  are  unless  careful  study 
is  made  of  various  series  of  statistics.  The  re- 
port of  the  British  Fracture  Committee  only  gives 
25  per  cent,  recovering,  good  functional  results  re- 
sulting from  the  conventional  method  of  treatment. 

FRACTURE  OF  THE  NECK  OF  THE 
FEMUR,  AT  BEST,  IS  ONE  OF  THE  MOST 
DIFFICULT  PROBLEMS  OF  ALL  SURGERY. 
THE  SLUGGISH  OSTEOGENESIS,  POOR 
BLOOD  SUPPLY,  DIFFICULTY  OF  FIXA- 
TION, AND  THE  ANATOMICAL  MECHAN- 
ICAL CONDITION,  all  are  potent  adverse  in- 
fluences in  securing  satisfactory  union  and  good 
functional  results.  If  radical  measures  are  justi- 
fiable in  any  vicious  fracture  of  the  bones  of  the 
body,  they  are  indicated  in  the  treatment  of  this 
desperate    disabling    condition. 

The  late  John  B.  Murphy,  who  did  so  much  in 
aiding  the  advancement  of  bone  surgery,  employed 


FRACTURES    OF   THE   FEMUR. 


181 


Fig.  87. — Fracture  of  neck  of  femur,  displaying  two  screws 
through  greater  trochanter,  and  through  neck  into  head,  with 
bony  union  resulting.     (/.  B.  Murphy.) 


182  MODERN    OPERATIVE   BONE    SURGERY. 

the  metal  spike  to  secure  better  approximation  and 
fixation  than  could  possibly  have  been  obtained  by 
non-operative  measures.  This  method,  however, 
has  not  given  good  uniform  results,  because  of 
the  bad  influence  of  the  metal  spike  on  sufficient 
callus  formation.  The  disadvantage  of  the  metal 
spike  is  overcome  by  the  use  of  a  strong  autog- 
enous bone-peg  accurately  applied  to  the  hole 
drilled  through  the  neck  of  the  femur.  The  frag- 
ments having  been  placed  in  accurate  anatomical 
relation,  with  a  rectangular  autogenous  bone-peg 
correctly  applied,  offers  unquestionably  the  most 
ideal  conditions  for  rapid  and  satisfactory  union 
of   this   most   difficult   of   all    fractures. 

The  influences  adverse  to  union,  which  are  so 
evident  in  fractures  of  the  neck  of  the  femur,  are 
better  overcome  by  this  procedure  than  by  any 
other  method  of  treatment.  Every  argument  in 
favor  of  the  autogenous  bone-peg,  intramedullary 
dowel,  or  inlay  graft,  in  selected  fractures  and 
ununited  fractures  of  the  shaft  of  long  bones, 
holds  equally  good  in  fractures  of  the  neck  of 
the   femur. 

The  autogenous  bone-graft  is  indicated  in  most 
unimpacted  fresh  fractures,  and  in  all  ununited 
fractures  of  the  neck  of  the  femur,  unless  physical 
condition  of  the  patient  contraindicates  the  neces- 
sary surgical  interference;  and  in  all  old  fractures 
of  the  neck,  or  at  the  epiphyseal  junction,  where 
malnutrition  has  resulted,  with  the  neck  depressed 
in  a  coxa-vara  relation  to  the  shaft.  In  such 
case,  an  osteotomy  is  made,  after  which  a  strong 
autogenous  bone-peg  is   applied. 


FRACTURES    OF    THE   FEMUR. 


183 


Fig.  88. — Fracture  of  the  hip  in  patient  aged  65  years. 
(J.  B.  Murphy.) 


184  MODERN    OPERATIVE   BONE    SURGERY. 

Technic  for  the  operation  for  the  repair  of 
fracture  of  the  neck  of  the  femur  by  the  use  of 
the  autogenous  bone  transplant  is  outlined  as 
follows : 

The  patient  should  be  placed  upon  a  traction 
table,  preferably  the  Geiger-Murphy,  which  will  allow 
simultaneous  abduction  and  traction.  The  fracture 
is  exposed  by  an  incision  starting  about  an  inch 
below  the  anterior-superior  spine,  and  extending 
downward  along  the  inner  border  of  the  sartorius 
muscle.  The  muscle  is  encountered  and  retracted 
inward.  The  fragments  are  now  in  view,  and  the 
debris  is  cleared  away  between  the  fractured  ends 
of  the  bone.  The  fragments  are  freshened  by 
careful   curretting. 

A  second  incision  is  made  along  the  outer  as- 
pect of  the  thigh,  over,  and  just  below,  the  great 
trochanter,  exposing  the  great  trochanter  and  the 
shaft  of  the  femur  immediately  below  it.  The 
limb  is  now  placed  in  abduction,  and  sufficient 
traction  is  applied  to  bring  the  fragment  into 
good  apposition,  aided  by  manipulation.  A  line 
should  now  be  gotten  on  the  direction  of  the  head 
and  neck  of  the  femur.  The  hole  to  be  made  for 
the  graft  should  be  made  to  pass  through  the 
middle  and  parallel  with  the  neck,  appearing  at 
the  cartilage  of  the  head  of  the  femur,  midway 
between  the  insertion  of  the  teres  ligament,  and 
the  superior  junction  of  the  head  and  neck.  The 
line  of  the  hole  can  be  easily  gotten  bv  placing 
a  straight  instrument  anterior  and  parallel  to  both 
distal    and    proximal    fragments. 


FRACTURES    OF   THE    FEMUR. 


185 


Fig.  89. — Same  as  Fig.  88,  displaying  two  12-penny  spikes 
driven  through  the  greater  trochanter,  and  through  neck  of 
femur  into  head.  Bony  union  followed  with  perfect  results. 
(7.  B.  Murphy.) 


186  MODERN    OPERATIVE    BONE    SURGERY. 

The  opening-  is  made  through  the  cortex  in 
the  outer  part  of  the  shaft  with  the  author's  elec- 
tric drill  at  the  level  which  will  give  the  direc- 
tion above  described.  The  fragments  are  held 
firmly  in  position  while  the  hole  is  bored  with 
a  %"  or  y2n  drill,  after  which  a  chisel  is  used 
to  square  the  hole,  both  in  the  proximal  and  dis- 
tal fragments,  which  requires  little  effort,  after 
passing  through  the  compact  tissue.  The  hole  or 
canal  extends  through  the  cancellous  bone,  across 
the  line  of  fracture  to  the  cartilage  of  the  head 
of  the  femur,  superior  to  the  attachment  of  -the 
ligament  teres,   as   above  described. 

Caution  must  be  used  not  to  pass  through  the 
head  of  the  bone  and  penetrate  the  hip-joint. 

Having  the  depth  and  diameter  of  the  canal,  a 
graft  is  now  removed  from  the  lower  portion  of 
the  shaft  of  the  tibia  or ^Jibula.  The  periosteum 
is  removed  from  the  graTE7  and  left  in  the  posi- 
tion of   its   original   location. 

After  carefully  dissecting  back  the  periosteum, 
if  the  graft  is  to  be  removed  from  the  tibia,  the 
Geiger  caliper  knives  are  used  to  get  the  exact  diam- 
eter of  the  graft  by  placing  the  caliper  knives  in 
the  prepared  canal,  and  setting  them,  then  using 
the  knives  to  lay  out  the  graft,  by  drawing  the 
knives  down  over  the  exposed  surface  of  the  tibia 
the  desired  length. 

Having  laid  out  the  graft,  the  author's  electric 
saw  is  now  brought  into  operation.  The  two  sides 
are  cut  through  very  quickly,  cutting  the  graft  as 
nearly    a    rectangle    as    possible.       The    ends    are 


FRACTURES    OF   THE   FEMUR  187 

released  now  by  using  the  author's  7/q±"  motor 
drill.  Several  holes  are  made  across  the  end  of  the 
graft,  after  which  a  chisel  is  used  to  cut  through 
and  relieve  the  ends  of  the  graft,  down  to  the 
marrow.  The  graft  is  picked  up  with  the  author's 
graft  retaining  forceps,  and  is  placed  in  the  canal 
prepared  for   it. 

The  graft  should  fit  snugly.  The  reason  that 
the  graft  is  made  rectangular  is  to  prevent  rotation 
of  one  fragment  of  bone  without  rotation  of  the 
other.  In  other  words,  it  absolutely  prevents  any 
motion  whatsoever  between  the  fractured  ends  of 
the  bone.  The  graft  once  in  position,  the  wound 
is  closed,  layer  by  layer,  with  absorbable  material; 
the  skin  is  closed  with  plain  gut,  subcuticular 
stitch;  gauze  dressing  is  applied  as  usual. 

[Marked  extension  is  kept  up  during  the  entire  op- 
erative procedure.  The  limb  is  put  up  in  an  abducted 
position  (Whitman's  position),  in  a  plaster-of-Paris 
spica,  extending  from  the  toes  to  above  the  waist- 
line. Before  the  plaster  is  entirely  dry,  a  window 
is  cut  in  it,  large  enough  to  permit  dressing  the 
wound.  The  wound  is  not  dressed,  however,  for 
two  Aveeks  unless  a  rise  of  temperature  follows. 
The  original  spica  is  left  on  for  six  weeks,  and 
at  the  end  of  this  time  it  is  removed,  and  re- 
placed by  one  extending  from  the  toes  to  the  hip. 

In  subtrochanteric  fractures  of  the  shaft,  the 
diagnosis  of  such  fracture  is  not  usually  difficult, 
as  the  displacement,  as  a  rule,  is  characteristic. 
The  upper  fragment  is  flexed  and  abducted;  the 
lower  fragment  overrides  the  upper  one,  and  is 
slightly   adducted. 


188  MODERN    OPERATIVE   BONE    SURGERY. 

In  a  great  man)/-  cases  it  is  almost  impossible 
to  correct  the  deformity  by  external  means,  and 
if  corrected  the  fragments  cannot  be  continuously 
held  in  :  apposition.  In  order  to  obtain  a  good 
result  in  the  majority  of  cases,  an  open  reduction 
with  internal  fixation  of  the  fragments  in  their  cor- 
rect alignment  and  rotation  is  very  essential. 

Access  to  the  fracture  is  gained  by  an  in- 
cision through  the  outer  part  of  the  thigh  from 
the  greater  trochanter  downward  over  the  line  of 
fracture.  The  upper  fragment  is  grasped  and 
held  by  the  author's  bone-retaining  clamp  (Fig. 
49),  while  the  fragment  is  prepared  for  the  intra- 
medullary dowel.  A  %"  or  %"  electric  drill  is 
used  first,  after  which  a  %"  or  %"  chisel  is  used 
to  square  the  hole.  Should  the  fracture  be  within 
three  inches  of  the  upper  portion  of  the  greater 
trochanter,  the  drill-hole  would  extend  upward, 
through  the  cancellous  bone,  passing  entirely 
through  the  fragment  in  line  with  the  intramedul- 
lary canal  of  the  femur.  The  upper  end  of  the 
lower  fragment  will  be  prepared  in  the  same 
manner. 

The  transplant  is  taken  from  the  shaft  of  the 
femur,  a  short  distance  below  the  line  of  fracture, 
or  from  the  the  crest  of  the  tibia  from  the  same 
limb  or  extremity,  the  periosteum  being  removed 
from  the  graft,  and  left  in  its  original  position. 
The  caliper  knives  are  used  to  get  the  exact  size 
of  the  canal  prepared,  and  the  dowel  is  cut  ac- 
cordingly. It  is  made  long  enough  to  pass  through 
the  small  upper  fragment,  and  to  enter  the  medul- 


FRACTURES  OF  THE  FEMUR.  189 

lary  canal  of  the  lower  fragment  a  sufficient  dis- 
tance to  give  firmness  thereto.  The  wound  is 
closed  layer  by  layer  in  the  usual  way,  and  dressed. 
The  extremity  is  immobilized  by  a  body  plaster- 
of-Paris  cast. 

The  thigh  having  been  previously  abducted  and 
rotated  outward  to  relax  the  muscles  attached  to 
the  greater  trochanter,  and  the  leg  slightly  flexed 
to  prevent  muscular  spasm,  spasm  probably  would 
cause  motion  of  the  transplant,  and  prevent  it 
grafting  to  its  new  bed.  The  cast  is  allowed  to 
remain  on  for  four  to  six  weeks,  at  which  time 
it  is  removed,  and  passive  motion  is  given  to  hip- 
and  knee-  joint.  Six  to  eight  weeks  after  the 
accident  the  patient  may  be  allowed  to  begin 
placing    part    of    the    body    weight    upon    the    limb. 

Fractures  of  the  shaft  (Fig.  90 J,  occur  most 
frequently  between  the  ages  of  20  and  60  years, 
and  are  most  common  in  working  people.  The 
causes  are  direct  and  indirect  violence,  and  mus- 
cular contraction.  Fractures  of  the  shaft  may  be 
complete  or  incomplete.  Incomplete  fractures,  how- 
ever, are  rare,  but  both  varieties  occur  in  adults 
as  well  as   children. 

Complete  fracture  of  the  shaft  may  be  multiple 
or  comminuted,  and  those  of  the  middle  third  are 
often  compound,  the  fragments  penetrating  the 
skin.  Injury  of  the  vessels  and  nerves,  although 
infrequent,  must  be  kept  in  mind,  however,  espe- 
cially in  the  supracondylar  fractures.  In  the  lat- 
ter  variety   the   lower    fragment   is   pulled   back   by 


190  MODERN    OPERATIVE   BONE    SURGERY. 

the  gastrocnemius  muscle,  and  may  penetrate  or  im- 
pinge upon  the  popliteal  vessels,  and  cause  gan- 
grene of  the  vessels,  with  fatal  hemorrhage  fol- 
lowing; or  in  case  of  complete  cessation  of  the 
circulation,   gangrene  of  the  leg. 

Fractures  near  the  middle  of  the  shaft  are  usu- 
ally oblique.  The  deformity  is  due  to  a  persist- 
ent overriding  of  the  fragments,  which  is  due  to 
continuous  contraction  of  the  muscles.  Reduction 
may  possibly  be  made,  but  as  a  rule  it  cannot 
be  continuously  maintained  by  traction  on  the  leg 
and  by   external   splints. 

The  use  of  the  intramedullary  dowel  is  indis- 
pensable in  fractures  of  the  middle  of  the  shaft 
of  the  femur  where  the  fragments  cannot  be  held 
in   position   by   external   means. 

The  graft  may  be  taken  from  below  or  above 
the  fracture  of  the  same  bone.  The  graft  taken 
from  such  locality  is  much  more  kindly  received 
by  the  host  than  if  procured  from  a  distant  part 
of  the  body,  as  previously  stated.  If,  however,  it 
is  not  feasible,  it  can  be  taken  from  the  shaft  of 
the  tibia  or  fibula   of  the   same  limb. 

To  bring  the  fragments  in  view,  a  longitudinal 
incision  is  made  along  the  outer  border  of  the 
thigh  at  a  level  that  will  expose  the  break.  The 
ends  of  the  fragments  are  turned  out  of  the 
wound  by  bending  the  thigh.  The  debris  is 
cleared  away.  The  fragment-ends  are  prepared, 
and  the  diameter  and  length  of  the  dowel  are  de- 
termined by  the  use  of  the  author's  caliper  knives, 
and     the    transplant     is     cut     accordingly,     without 


FRACTURES    OF   THE   FEMUR. 


191 


Fig.  90. — Antero-posterior  view  of  fracture  of  the  femur  at 
a  junction  of  the  middle  with  the  lower  third,  after  fixation  of 
the  fragments  by  a  sliding  inlay-graft  from  the  upper  frag- 
ment. Also  showing  bone-pegs  giving  rigidity  and  firmness  to 
the  graft. 


192  MODERN"    OPERATIVE    BONE    SURGERY. 

periosteum.  The  length  of  the  graft  is  largely 
governed  by  the  condition  of  the  fractured  ends 
of  the  bone.  If  the  fracture  is  transverse,  a  3" 
transplant  is  long  enough,  but  should  it  be  an 
oblique  or  spiral  or  comminuted  break,  the  length 
of  the  graft  is  entirely  governed  by  the  extent  of 
the  splintering,  etc.,  of  the  ends  of  the  bone.  The 
graft  should  extend  at  least  an  inch  or  more  into 
healthy  bone. 

In  all  cases,  the  fractured  ends  of  the  bone  are 
always  prepared  before  removing  the  transplant 
from  its  original  bed,  because  the  transplant  should 
be  transferred  from  the  original  location  to  the 
recipient  bone  in  the  shortest  possible  time,  with- 
out placing  it  in  any  solution,  or  coming  in  con- 
tact with  any  liquid,  or  drying  the  life  fluid,  in 
which  it  is  bathed.  The  original  blood  and  serum 
which  covers  the  transplant  is  always  very  essen- 
tial to  its  life,  and  should  not  be  removed  or 
disturbed. 

If  the  author's  method  is  not  used  (see  p.  158) 
and  the  usual  plan  is  carried  out  in  placing  the 
transplant  in  position  in  the  fragments  in  frac- 
tures of  the  femur,  the  thigh  is  bent,  as  previously 
stated,  to  give  free  and  unhampered  access  to  the 
broken  ends  of  the  bone.  The  dowel  transplant  is  first 
placed  in  the  lower  fragment,  and,  by  extension  and 
manipulation,  the  free  end  is  introduced  into  the 
upper  fragment.  After  carefully  examining  the 
fracture  to  see  whether  the  fragments  are  in  per- 
fect apposition,  the  wound  is  closed  in  the  usual 
manner.     Great  care  must  be  exercised  in  handling 


FRACTURES    OF   THE   FEMUR.  193 

the  limb  while  placing  it  in  the  fixed  dressing, 
which  is  immobilized  in  a  plaster-of-Paris  body- 
cast;  this  is  allowed  to  remain  for  five  or  six 
weeks,  when  it  is  removed,  and  the  patient  allowed 
to   gradually  resume  the  use  of   the  limb. 

Supracondyloid  fractures,  or  fractures  of  the 
lower  end  of  the  shaft  of  the  femur,  are  usually 
transverse,  and  may  be  treated  by  the  external 
method.  However,  should  it  require  an  operative 
procedure,  and  subjected  to  open  reduction  and 
fixation,  the  intramedullary  dowel  should  be  some- 
what larger  than  when  used  in  the  middle  of 
the  shaft,  as  the  medullary  canal  in  the  lower 
end  of  the  bone  or  near  the  joint  is  large,  and 
the  cancellous  bone  is  softer.  The  transplant  in  the 
lower  fragment  will  require  but  little  fitting.  The 
dowel-transplant  may  be  removed  from  the  shaft 
of  the  femur,  near  the  fracture,  or  from  the  tibia, 
or  fibulae,  without  periosteum.  If  taken  from  the 
shaft  near  the  fracture,  the  medullary  canal  is 
used  to  pass  the  transplant  through  the  fragments 
into  the  desired  position.  If  the  conventional  method 
is  used,  the  transplant  is  first  placed  in  the  upper 
fragment,  and,  by  manipulation  and  extension,  is 
placed  in  the  lower  one.  It  is  sometimes  neces- 
sary to  make  a  %'"  drill-hole  through  the  lower 
fragment  and  the  transplant,  through  which  a 
large  kangaroo  tendon  is  placed  and  tied,  to  pre- 
vent the  transplant  from  passing  down  too  far  into 
the  lower  fragment.  The  wound  is  closed,  and 
the  limb  is  placed  in  a  body  plaster-of-Paris  cast, 
and  allowed  to  remain  for  four  to  five  weeks. 

13 


194  MODERN    OPERATIVE   BONE    SURGERY. 

The  fractures  of  the  lower  end  of  the  femur 
are  intercondyloidal,  fractures  of  either  condyle, 
and  separation  of  the  lower  epiphysis.  In  the  in- 
tercondyloidal variety,  the  line  of  fracture  is  either 
T-  or  Y-  shaped.  The  fracture  is  very  likely  to 
be  compound,  and  associated  with  injuries  of  the 
popliteal  vessels.  The  diagnosis  is  made  from 
the  independent  mobility  of  the  two  condyles  on 
each  other  by  moving  them  backward  and  for- 
ward, and  by  the  pain  when  they  are  pressed  to- 
gether. An  effusion  into  the  knee-joint  is  ever 
present,  and  often  makes  difficult  the  recognition 
of  the  fracture.  To  make  a  sure  diagnosis,  the 
X-ray   should   be   used. 

Separation  of  the  lower  epiphysis  of  the  femur 
is  next  in  frequence  to  epiphyseal  separation  of 
the  upper  end  of  the  humerus.  Usually  the  epi- 
physis is  displaced  forward  and  the  shaft  pulled 
backward  by  the  gastrocnemius  muscle.  This  dis- 
placement in  many  cases  endangers  the  popliteal 
vessels.  The  epiphysis  may  be  rotated  90  degrees, 
so  that  its  joint  surface  faces  the  patella  when 
the  limb  is  straight;  the  same  position  that  you 
would  find  when  the  leg  is  flexed  at  right  angle 
with  the  thigh.  An  X-ray  examination  should  be 
made  before  and  after  reduction.  In  fractures  of 
either  the  outer  or  inner  condyle,  the  fragments 
may  impinge  upon  the  articulation,  endangering* 
the  movements  of  the  knee-joint;  this  condition 
may  recur  and  exist  after  the  best  external  reduc- 
tion that  can  be  made.  When  this  does  occur, 
an  incision   should  be   made  over  the  injured   con- 


FRACTURES    OF   THE   FEMUR.  195 

dyle,  exposing  the  fracture.  After  placing  the 
fragments  in  anatomical  relation  with  the  frac- 
tured end  of  the  shaft,  a  drill-hole  is  passed 
through  it,  upward,  at  the  binding  angle,  through 
the  cancellous  bone  of  the  lower  end  of  the  femur, 
and  through  the  compact  bone,  on  the  opposite 
side.  A  quadrangular  transplant  is  removed  from 
the  crest  of  the  tibia,  without  its  periosteum;  the 
transplant  should  fit  snugly,  so  as  to  pin  the  frag- 
ment to  the  femur  shaft. 

Should  both  the  internal  and  external  condyles 
be  fractured  at  the  same  time,  two  dowel-trans- 
plants can  be  used,  the  holes  being  made  into  the 
lower  end  of  the  femur,  so  that  the  transplants 
or  bone-peg  will  not  come  in  contact  ■  with  each 
other,  but  will  cross  each  other  approximately  at 
the   middle   of   the   upper   third. 

The  limb  is  placed  in  the  semiflexed  position, 
and  the  foot,  leg,  and  thigh  are  placed  in  a  plas- 
ter-of-Paris  dressing,  and  allowed  to  remain  for 
five  or  six  weeks,  after  which  passive  motion  is 
made,  and  the  patient  is  allowed  to  begin  to  bear 
weight  at  the  end  of  six  or  seven  weeks. 


CHAPTER  XXVI. 

Fractures  of  the  Patella. 

Fractures  of  the  patella  occur  most  frequently 
between  the  ages  of  35  and  50  on  account  of  the 
activity  of  people  at  this  age.  A  thorough  knowl- 
edge of  the  anatomical  relations  of  the  patella  is 
necessary  to  have  a  perfect  understanding  of  the 
fractures  to  which  this  bone  is  liable.  On  its 
upper  border  the  tendon  of  the  quadriceps  exten- 
sor muscle  is  attached.  On  each  side  of  the  bone 
are  attached  the  vastus  interims  and  vastus  exter- 
nus  respectively.  Below  the  insertion  of  the  vasti 
is  a  portion  of  the  lower  attachment  of  the  fascia 
lata  of  the  thigh. 

On  the  lower  border  of  the  patella  is  attached 
the  patella  tendon,  the  lower  end  of  which  is  in- 
serted into  the  tubercle  of  the  tibia,  and  is  sep- 
arated from  the  head  of  the  tibia  by  a  bursa,  in 
a  pad  of  fat-tissue.  The  tendon  of  the  quadriceps, 
insertion  of  the  vasti  muscles,  and  the  patella,  are 
all  continuous  with  the  strong  fascia  lata  sur- 
rounding the  thigh   in  this   region. 

The  fascia  lata  is  attached  posterior  and  below 
to  the  condyles  of  the  femur,  the  sides  of  the 
patella,  the  tuberosities  of  the  tibia,  the  head  of 
the  fibula,  and  to  the  deep  fascia  of  the  leg,  in 
the  popliteal   space. 

The  patella,  therefore,  lies  in  a  strong  fibrous 
(196) 


FRACTURES  OF  THE  PATELLA. 


197 


sheath    that    encircles    the    knee,    and    which    is    at- 
tached to   various  bony  prominences. 

The    synovial    membrane   of    the    knee-joint   lies 
directly  beneath,  and  attached  to  the  posterior  sur- 


Fig.  91. — Fracture  of  the  patella,  with  fragments  about 
two  inches  apart. 

face  of  the  patella.  The  deep  bursa  of  the  patella 
lies  in  front  of  the  lower  end  of  the  femur,  be- 
neath the  quadriceps  muscle,  and  often  communi- 
cates with  the  knee-joint.  When  the  leg  is  com- 
pletely extended,  and  is  at  rest,  the  outline  and  the 
anterior    surface    of    the    patellae    can    be    palpated 


198 


MODERN    OPERATIVE   BONE    SURGERY. 


and  moved  from  side  to  side.  Long  striae  of  con- 
siderable number  can  be  detected  on  the  anterior 
surface  of  the  patella.  In  these,  tendinous  bundles 
of  insertion  of  the  rectus  are  embedded.  It  is 
these   fibers   that    fold   between    the   broken    patella 


Fig.  92. — Same  as  Fig.  91.  Shows  fractured  fragments  of 
patella  wired  together  by  bronze  wire.  Bony  union  resulted 
with  perfect  use  of  membrane.     (/.  B.  Murphy.) 

fragments  and  prevent  the  complete  reduction  or 
approximation  of  the  fragments.  The  patella  liga- 
ment is  parallel  with  the  thigh  bone.  Eighty  per 
cent,  of  all  fractures  of  the  patella  are  the  result 
of    direct    violence,    such    as    a    fall    or    blow    upon 


FRACTURES    OF   THE    PATELLA. 


199 


the  knee.     The  remainder  are  due  to  muscular  con- 
traction and  indirect  violence. 

The  prognosis  as  to  complete  functional  res- 
toration without  surgical  interference  in  fracture 
of  the  patellae  is  bad.  Bony  union  occasionally 
occurs,  but  it  is  very  rare.  It  is  advisable,  then, 
to  operate  on  all  fractures  of  the  patellae,  in  order 
to  obtain  the  best  results  in  all  cases.  To  reach 
the  fragments,  a  U-shaped  flap  is  made,  with  the 
apex  of  its  convexity  over  the  patella  ligament, 
and    its    base    over    the    condyles    of    the    femur. 


Fig.  93. — Spool-shaped  type  of  inlay-graft  usually  used  in 
fracture  of  patella,  showing  bone-pegs  in  position  holding  graft 
firmly  in  its  bed. 

After  bringing  in  view  the  fragments,  all  blood- 
clots  and  particles  of  fibrous  tissue  are  cleansed 
away,  and  the  fragments  are  adjusted,  in  case  it 
is  a  fresh  fracture.  If  it  is  a  refracture,  or  fib- 
rous union,  the  fragment  ends  are  thoroughly 
freshened,  after  which  the  fragments  are  brought 
in  perfect  apposition.  The  periosteum  is  first  re- 
moved from  the  anterior  and  center  portion  of  the 
patellae,  splitting  the  periosteum  from  above  down- 
ward,   through    the    center,    and   turning   the    flaps 


200  MODERN    OPERATIVE   BONE    SURGERY. 

aside.  Now  the  field  is  ready  for  laying  out  the 
bed  or  gutter  to  receive  the  inlay.  The  broken 
patella  fragments  are  brought  in  close  contact. 
The  caliper  knives  with  the  scalpel  are  used  in 
making  the  design  or  outline  on  the  anterior  sur- 
face of  the  bone.  A  cylinder-with-flange-at-each- 
end  or  spool-shaped  outline  is  made  (Fig.  93). 
With  the  author's  %"  motor  saw,  cuts  or  fur- 
rows are  made  to  the  depth  of  Va"?  following  the 
outlines  previously  made.  The  fractured  surfaces 
of  the  fragments  are  now  tilted  forward,  and 
with  a  thin,  narrow,  sharp  chisel  or  osteotome  the 
bone  within  the  previously  made  saw-cuts  is  re- 
moved to  a  depth  of  %"  to  %2"  from  the  an- 
terior surface  of  the  patella,  after  placing  the 
fragments  in  perfect  apposition.  Again  the  cali- 
per knives  are  used  to  make  careful  measurements 
of  the  bed  or  inlay-gutter. 

The  inlay  is  now  taken  from  the  anterior  and 
upper  portion  of  the  tibia,  where  the  surface  is 
broad  and  the  cortex  thin.  The  graft  must  be 
removed  with  the  periosteal  covering.  The  author, 
as  a  rule,  uses  either  a  piece  of  oil  linen  or  sheet- 
lead  which  has  been  sterilized,  and  cut  in  the 
shape  of  the  inlay  to  be  used;  this  is  used  as  a 
model  in  modeling  or  shaping  the  bed  or  gutter, 
and  in  outlining  the  graft.  The  graft  is  removed 
with  the  author's  bone-graft  retaining  forceps,  and 
placed  in  position  in  the  gutter  or  bed.  Great 
care  must  be  taken  in  removing  and  placing  the 
graft  in  position,  to  produce  as  little  trauma  as 
possible.     One-eighth  inch  drill-holes  are  now  made 


FRACTURES    OF   THE    PATELLA. 


201 


through  the  upper  fragment  and  inlay  graft,  mid- 
way between  the  free  surface  of  the  fragment  and 
the  upper  end  of  the  graft  (Fig.  94).  A  hole 
also  is  made  in  the  same  position  in  the  lower 
fragment;  %"  pegs  are  placed  in  these  two  holes, 
extending  entirely  through  the  patella  fragments, 
from  side  to  side.  These  pegs  immobilize  and 
hold  the  graft  in  position,  while  bony  union  takes 
place    between    the    graft    and    the    recipient    bone. 


Fig.  94. — Shows  inlay  graft  with  enlarged  or  dilated  ends 
used  in  fracture  of  the  patella,  for  bridging  across  where  frag- 
ments cannot  be  brought  into  apposition.  Also  illustrates  the 
inlay,  held  in  position  by  bone-pegs. 


The  capsule  is  now  sewed  together  with  kangaroo 
tendon  or  twenty-day  gut. 

In  stellated  fractures  of  the  patella,  it  may  be 
necessary  to  use  dowels  or  pegs  in  place  of  the 
inlay;  and  in  certain  cases,  in  addition  to  the 
dowel  or  inlay,  it  is  advisable  to  use  a  suture  of 
kangaroo  tendon  to  hold  the  fragments  together 
more  securely,  placing  the  tendon  entirely  around 
the  patella,  laterally  through  the  quadriceps  ten- 
don, and  the  ligament  patella,  and  tying  it  tightly. 


202  MODERN    OPERATIVE   BONE    SURGERY. 

The  skin  incision  is  closed  subcuticularly  with 
plain  gut  suture;  the  limb  is  placed  in  a  plaster- 
of-Paris  dressing  for  thirty-five  to  forty  days,  at 
the  end  of  which  time  it  is  removed,  and  pas- 
sive motion  of  the  knee-joint  is  made.  :  Within 
six  to  eight  weeks  the  patient  is  permitted  to  use 
the  limb  in  a  moderate  way. 


CHAPTER  XXVII. 

Fractures  of  the  Tibia  axd  Fibula. 

Fracture  of  the  shaft  of  the  tibia  occurs  most 
frequently  from  direct  violence.  Fractures  of  the 
tibia  and  fibula  usually  occur  from  indirect  vio- 
lence. The  line  of  fracture  is  most  often  oblique, 
although   spiral   fractures   occur   quite  often. 

The  X-ray  should  be  used  in  all  cases  in  mak- 
ing a  diagnosis,  for  if  it  is  a  spiral  fracture  it  is 
almost  impossible  to  perfectly  reduce  such  fracture, 
or  hold  it  in  apposition  after  it  has  been  reduced. 
In  the  oblique  form,  the  line  of  fracture  runs 
from  below,  and  anteriorly,  backwards  and  up- 
ward: the  upper  fragment  is  often  displaced  for- 
ward to  such  an  extent  as  to  lie  directly  beneath 
the  skin.  In  some  oblique  fractures,  it  is  also 
difficult  to  hold  the  fragments  in  perfect  align- 
ment. In  all  spiral,  and  in  a  great  many  oblique, 
fractures,  it  is  necessary  to  resort  to  the  open 
method.  In  acute  fractures  of  the  shaft,  the  in- 
tramedullary transplant  is  preferable  because  it 
seiwes  the  one  purpose  better  than  the  inlay.  The 
purpose  or  function  of  the  transplant  in  fresh 
fractures  of  the  shaft  of  the  tibia,  is  to  hold  the 
fragments  in  perfect  apposition.  When  the  dowel 
is  properly  applied,  the  broken  bone  cannot  be 
out    of    alignment. 

To    expose    the    fracture,    a    curved    incision    is 

(203, 


204  MODERN    OPERATIVE   BONE    SURGERY. 

made  over  the  shin.  If  the  tibia  and  fibula  are 
both  fractured,  at  about  the  same  level,  reduction 
is  easy.  Should  the  fibula  be  fractured  at  a  dif- 
ferent level,  or  if  the  fragments  are  impacted,  re- 
duction, as  a  rule,  is  difficult,  and  in  some  cases 
it  is  necessary  to  fracture  surgically  the  fibula  at 
a  point  opposite  the  break  in  the  tibia.  The  blood- 
clots  and  shreds  of  fibrous  tissue  and  bone  pro- 
duced by  the  injury,  are  cleared  from  the  wound, 
and  the  fragments  are  prepared  for  the  reception 
of  the  transplant. 

The  transplant  should  be  rectangular  in 
shape,  so  that  when  it  is  applied  it  will  act  as  a 
key  to  prevent  rotation  of  the  fragments  when  the 
broken  ends  are  brought  together.  The  broken 
ends  of  the  bone  are  now  grasped  with  the 
author's  bone  elevating  forceps,  and  held  firmly 
while   they   are   being   prepared. 

If  a  graft  %"  in  diameter  is  to  be  used,  a 
%"  hole  of  the  depth  desired  is  made  in  each 
fragment  with  the  author's  motor  drill.  A  %" 
chisel  is  then  used  to  square  the  hole.  The  peg 
or  dowel  should  fit  snugly.  It  is  first  introduced 
into  the  lower  fragment  and  is  brought  into  the 
upper  fragment  by  bending  and  extending  the  dis- 
tal portion  of  the  limb.  The  dowel  in  place,  and 
the  fragments  in  perfect  anatomical  relation,  the 
wound  is  closed  with  absorbable  material,  and 
dressed  with  plain  gauze.  A  plaster-of-Paris  dress- 
ing is  applied,  beginning  at  the  toes,  and  extend- 
ing two-thirds  up  the  thigh,  which  is  allowed  to 
remain   for    four    to   five   weeks,    after    which    it   is 


FRACTURES    OF   THE   TIBIA   AND   FIBULA. 


205 


Fig.  95. — A,  fracture  of  lower  portion  of  tibia  and  fibula, 
with  bad  deformity.  B,  same  as  A.  Taken  six  weeks  after 
application  of  intramedullary  dowel ;  with  perfect  alignment  and 
good  bony  union  of  both  tibia  and  fibula. 


206  MODERN    OPERATIVE   BONE    SURGERY. 

removed,  and  the  patient  gradually  allowed  to  use 
the  limb.  Fractures  of  the  lower  end  of  the  tibia 
and  fibula  are  all  given  the  name  of  "Pott's  frac- 
ture." The}<r  may  be  either  the  result  of  forcible 
eversion   or   inversion. 

As  a  rule,  diagnosis  can  easily  be  made.  Where 
there  is  a  fracture  of  the  internal  malleolus,  with 
displacement  to  such  an  extent  that  the  mortise  of 
the  joint  is  separated,  or  where  the  fragments  im- 
pinge upon  the  articulation  in  a  manner  which 
checks  free  motion,  an  incision  should  be  made 
exposing  the  seat  of  fracture  and  the  fragments. 
The  malleolus  should  be  fastened  to  the  tibia  in 
its  normal  relations  to  the  bone  and  ankle-joint  by 
an  autogenous  bone-peg  or  dowel.  The  peg  trans- 
plant will  mechanically  hold  the  fragment  in  posi- 
tion, until  bony  union  takes  place  between  the 
malleoli  fragment  and  the  tibia. 

The  wound  is  closed  as  usual,  and  dressed 
with  plain  gauze,  and  a  plaster-of-Paris  cast  is 
applied,  extending  from  the  toes  to  the  knee, 
which  is  allowed  to  remain  for  four  or  five  weeks, 
after  which  time  it  is  removed,  and  passive  motion 
is  made  of  the  ankle.  After  five  or  six  weeks 
the  patient  is  gradually  allowed  to  regain  the  use 
of   the   foot. 


CHAPTER  XXVIII. 

Fractures  of  the  Os   Calcis. 

Fractures  of  the  os  calcis  are  due  to  compres- 
sion in  the  majority  of  cases.  The  patient  falls 
from  a  height  to  the  ground,  striking  on  his  heel. 
The  os  calcis  is  crushed  between  the  astragalus 
and  the  ground.  Fracture  of  the  os  calcis  is  by 
far  the  most  common  fracture  of  the  bones  of  the 
foot. 

Fracture  of  the  os  calcis  may  be  divided  into 
three  general  types:  type  A,  the  fracture  confines 
itself  largely  to  that  portion  lying  behind  a  ver- 
tical line  to  the  middle  of  the  body  of  the  astrag- 
alus; type  B  includes  all  cases  of  extensive  com- 
minution of  the  anterior  half  of  the  os  calcis;  type 
C  includes  all  cases  of  extensive  comminution  of 
the  bone.  Abbott  states  that  in  such  cases  the 
bone    is    literally    "shattered." 

Type  A  is  the  only  one  of  the  three  to  be  con- 
sidered in  this  connection.  In  treatment  of  frac- 
tures of  the  os  calcis,  the  most  important  point  is 
to  reserve  or  restore  the  arch  of  the  foot,  for  the 
purpose  of  function,  as  well  as  from  the  cosmetic 
standpoint. 

As  previously  stated,  the  X-ray  should  be  used 
in  perfecting  the  diagnosis  of  all  fractures,  and 
this    one    is    not   excepted. 

(207) 


208  MODERN    OPERATIVE   BOXE    SURGERY. 

To  bring  in  view  the  fracture,  an  incision  is 
made  along  the  outside  of  the  tendo  Achillis,  down 
to  the  edge  of  the  plantar  skin,  then  passing  in- 
ternally around  the  posterior  part  of  the  heel. 
The  flap  thus  outlined  is  freed  from  the  poste- 
rior end  of  the  os  calcis  and  drawn  inward.  In 
loosening  the  flap,  one  should  keep  close  to 
the  bone,  so  the  circulation-flap  will  not  be  inter- 
fered w7ith. 

The  fragment  is  now  grasped  with  the  author's 
bone  forceps.  It  may  be  necessary,  in  order  to 
loosen  the  fragment,  to  force  the  heel  from  right 
to  left.  In  some  cases,  in  order  to  bring  the 
fragment  into  position,  it  is  necessary  to  tenoto- 
mize  the  tendo  Achillis,  which  must  be  done  under 
strict  precautions  not  to  cut  anteriorly,  but  place 
the  tenotome  with  the  cutting  edge  towards  the 
skin,   so  as  not  to  harm  the   blood   supply. 

The  posterior  fragment  in  position,  a  hole  %" 
in  diameter  is  made  with  the  author's  motor  drill, 
in  line  with  the  axis  of  the  bone  (as  shown  in 
Fig\  96).  The  drill-hole  should  start  in  the  pos- 
terior and  center  portion  of  the  os  calcis.  The 
hole  should  extend  at  least  1"  beyond  the  line  of 
fracture,  but  it  should  not  extend  into  or  beyond 
the  articulation  of  the  os  calcis  with  the  as- 
tragalus. It  is  well  to  leave  the  drill  in  position 
in  the  hole  until  the  dowel  or  peg  has  been  pre- 
pared. The  transplant  should  be  removed  from 
the  anterior  surface  of  the  tibia  of  the  same  leg. 
With  the  author's  tube  saw  and  lathe  attachment, 
the    transplant   is    converted    into    the    nail    or    peg 


FRACTURES    OF   THE   OS    CALCIS. 


209 


Fig.  96. — Transverse  fracture  of  the  os  calcis  showing  a 
dowel  used  to  hold  fragments  in  position  and  to  stimulate 
osteogenesis. 


14 


210  MODERN    OPERATIVE   BONE    SURGERY. 

with  rapidity  and  ease,  without  the  service  of  an 
assistant.  The  end  of  the  peg  must  not  project 
out  beyond  the  surface  of  the  os  calcis,  as  it 
would  cause  pressure  on  the  skin,  and  possible 
necrosis. 


CHAPTER  XXIX. 

Fractures  of  the   Spine. 

In  fracture-dislocations  of  the  spine,  where 
one  or  more  vertebral  bodies  are  involved,  Pal- 
mar recommends  an  immediate  laminectomy,  ex- 
posing thoroughly  the  spinal  cord,  followed  by  an 
immediate  permanent  osteoplastic  fixation  of  the 
vertebra  involved  with  attempt  of  ankylosis  of  the 
two  vertebras  above  and  two  below  the  fractured 
and  misplaced  vertebra.  After  completion  of  the 
laminectomy  of  the  one  or  more  vertebras  involved, 
the  incision  is  extended  in  both  directions.  Two 
spinous  processes  above  and  two  below  the  affected 
vertebras  are  exposed.  The  four  healthy  spinous 
processes  with  their  attached  ligaments  are  split 
en  masse,  with  a  wide  chisel,  leaving  two-thirds 
on  one  side,  and  one-third  on  the  other.  The 
latter  portion  is  broken  over  to  make  a  gutter 
for  the  transplant.  A  strong  transplant,  long 
enough  to  overlap  the  defect  and  the  two  vertebras 
above  and  below,  is  taken  from  the  anterior  sur- 
face of  the  tibia,  with  the  author's  motor  saw, 
with  the  periosteum  left   intact. 

The  transplant  should  be  V-shaped,  and  should 
be  placed  in  the  gutter  in  such  position  that  there 
will  be  twro  bone  contacts;  the  bony  contact  must 
be  on  both  sides  of  the  graft.  The  graft  is  held 
in  position  by   %"  bone-pegs,  which  are  placed  in 

(211) 


212  MODERN   OPERATIVE   BONE   SURGERY. 

holes  made  through  the  spinous  processes  of  the 
healthy  vertebra  and  the  transplant.  The  wound 
is  closed  in  layers,  with  absorbable  sutures;  the 
skin  is  closed  with  subcuticular  stitch;  the  wound 
is  dressed  with  plain  gauze,  and  a  body  plaster- 
of-Paris  jacket  applied,  to  immobilize  the  spine, 
and  allowed  to  remain  on  for  eight  weeks.  In 
some  cases,  it  is  necessary  to  cut  a  window  in 
the  cast  over  the  seat  of  injury,  in  order  to  be 
able  to  change  the  dressing. 


CHAPTER  XXX. 

Postoperative  Fractures   of  Tibia. 

By  removing  a  segment  of  the  crest  or  any 
portion  of  the  tibia  opening  into  the  medullary 
canal,  it  is  weakened  out  of  all  proportion  to  the 
amount  of  bone  excised,  because  it  interferes  with 
the  tubal  relations  of  the  cortical  bone.  During 
the  removal  of  the  transplant,  it  must  be  remem- 
bered that  the  tibia  is  being  robbed  of  its  func- 
tional bone;  that  the  amount  of  bone  removed 
must  be  limited  to  the  least  portion  that  will 
serve  for  the  transplantation;  and  that  the  manner 
of  the  removal  must  conserve  the  strength  of  the 
mutilated  tibia.  The  ruthless  methods  used  in 
cutting  the  tibia  at  the  end  of  the  transplant  tem- 
porarily weaken  the  bone  to  the  extent  of  the 
over-cutting.  In  place  of  using  the  circular  saw 
in  freeing  the  end  of  the  transplant,  the  author 
suggests  that  the  %4/r  motor  drill  be  used,  mak- 
ing the  holes  across  the  end  of  the  transplant  in 
close  proximity,  after  which  a  chisel  is  used  to 
completely  sever  the  end  of  the  transplant  from 
its   bed. 

The  possibilities  of  postoperative  fractures  of 
the  tibia  are  increased  in  proportion  to  the  size  of 
the  transplant  removed,  or  in  proportion  to  the 
amount  of  damage  done  to  the  bony  cylinder  by 
unskillful  and  unguarded  technic  during  the  re- 
moval,   and   a   great   number   of   fractures   has    oc- 

(213) 


214  MODERN    OPERATIVE   BONE    SURGERY. 

curred  to  the  donor  bone  on  account  of  careless- 
ness on  the  part  of  the  surgeon.  The  removal  of  the 
graft  for  purpose  of  transplantation  is  replaced  by 
a  deposit  of  new  bone;  the  rapidity  with  which  it 
is  replaced  depends  upon  the  size  of  the  trans- 
plant removed,  and  the  age  and  physical  condi- 
tion of  the  patient  (Murphy).  "Responding  to 
functional  demands  for  strength,  bone  is  regener- 
ated in  the  defect,  and  bone-hypertrophy  takes 
place,  until  the  equilibrium  between  the  function 
and  strength   has   been   established." 

In  all  cases  where  a  transplant  has  been  re- 
moved from  the  tibia,  it  should  be  protected  against 
fracture  by  a  plaster  cast  during  the  period  of 
regeneration  of  the   defect  caused  by  the  removal. 

In  removing  a  portion  of  the  shaft  of  the 
fibula  for  transplantation  purposes,  where  the  epi- 
physes are  undisturbed  and  the  periosteum  re- 
mains, it  is  more  than  likely  that  the  entire  seg- 
ment will  be  regenerated.  Especially  is  this  true 
if  it  is  in  a  vigorous  young  person.  Age  and 
debility  may  entirely  prevent  bone-regeneration.  If 
the  patient  is  young  and  vigorous,  and  the  entire 
periosteum  remains  in  a  healthy  state,  as  just 
stated,  the  whole  diaphysis  of  the  long  bone  may 
be  regenerated. 

In  case  of  removal  of  the  fibula  for  grafting 
purposes,  and  failure  of  regeneration  takes  place, 
when  a  segment  of  the  whole  thickness  has  been 
removed  for  transplantation,  a  compensatory  hy- 
pertrophy of  the  tibia  will  occur  to  take  care  of 
the  functions   of   the  bone   that   was   removed. 


CHAPTER  XXXI. 

Delayed  Union  and  Ununited  Fractures. 

When  the  usual  time  required  for  a  fracture  to 
unite  has  passed,  and  solid  bony  union  between 
the  fragments  has  not  taken  place,  delayed  union 
is  now  said  to  exist.  The  time  is  comparative  be- 
tween the  physiological  repair  of  fractures,  when 
union  becomes  delayed,  or  when  delayed  union  be- 
comes nonunion.  After  an  indefinite  time,  delayed 
union  may  become  firmly  united,  or  may  result  in 
nonunion.  In  delayed  union  it  is  a  rule  to  find 
that  the  callus  has  covered  the  ends  of  the  frag- 
ments, and  united  them,  but  has  remained  soft,  or 
it  has  not  ossified.  The  osteoblasts  liberated  from 
the  fragments  by  the  injury  and  subsequent  changes 
riave  failed  to  do  their  duty  of  filling  the  cal- 
lus with  active,  creative  elements  of  new  bone,  and 
have  failed  to  stimulate  the  deposition  of  cal- 
careous salts  in  the  callus  at  the  proper  time.  In 
the  presence  of  these,  or  under  such  conditions, 
the  physiological  ossification  of  the  callus  does  not 
follow.  Also  the  presence  of  metal  or  any  for- 
eign body,  such  as  a  material  for  fixation,  retards 
osteogenesis  between  the  broken  ends,  and  hinders 
hony   union   of   the   ununited   fracture. 

The  things  necessary  to  produce  bony  union  in 
ununited  fractures  are:  (i)  the  removal  of  the 
eburnated  bone,  or  the  extension  of  an  autogenous 

(215) 


216  MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  97. — A,  fracture  of  tibia  and  fibula,  with  nonunion  after 
wiring  of  the  tibia.  B,  same  as  A.  Two  years  after  operation. 
An,  intramedullary  dowel  was  used,  but  by  this  time  it  cannot 
be  seen.  A  wire  nail  which  is  still  in  position,  was  also  driven 
through  fragments.  Head  of  a  small  screw  was  lost  in  wound; 
this  can  be  seen  on  both  skiagraphs. 


DELAYED   UNION   AND   UNUNITED   FRACTURES.    217 

bone-graft  far  enough  into  both  fragments  to  con- 
tact with  healthy  bone;  (2)  fixation  of  the  frag- 
ments in  perfect  alignment,  and  stimulation  of 
osteogenesis  in  the  area  of  nonunion,  by  the  ap- 
plication of  an  autogenous  transplant;  the  trans- 
plant grows  and  stimulates  the  production  of  bone- 
callus  in  and  around  the  ununited  fracture,  until 
normal  conditions  exist;  finally,  the  part  becomes 
solidified,  and  the  transplant  and  callus  are  ab- 
sorbed as  the  functional  requirements  for  their 
presence  gradually  lessen,  and  finally  cease  to 
exist.  The  new  bone  ultimately  reaches  a  per- 
manent  basis. 

The  autogenous  transplant  in  ununited  fracture 
has  one  special  function,  viz.',  stimulation  of  osteo- 
genesis in  the  ends  of  the  ununited  bone.  In  un- 
united fractures,  as  a  rule,  after  the  ends  of  the 
bone  have  been  thoroughly  prepared,  perfect  align- 
ment is  very  easily  retained.  The  inlay  graft  or 
cortical  transplant  is  much  superior  to  the  intra- 
medullary dowel  or  peg,  as  it  possesses  a  superior 
quantity  of  stimulating"  elements  in  the  growth  of 
bone,  which  is  most  essential  in  ununited  fractures. 

In  the  delayed  union,  or  ununited  fracture,  the 
causes  are  many  and  varied,  and  may  be  divided 
into  local  and  general  constitutional  conditions  of 
the  patient.  The  local  causes  may  be  classified 
as  follows:  The  presence  of  muscle,  fibrous  tissue, 
or  tendon  between  the  fractured  ends  of  the  bone; 
imperfect  immobilization  of  the  part  during  re- 
pair; impoverished  blood  supply  to  the  lower  frag- 
ment,   when    the    fracture    is     situated    near    the 


218 


MODERX    OPERATIVE   BOXE    SURGERY. 


Fig.  98. — Skiagraph  of  ununited  fractures  of  tibia  and  fibula 
in  child.  Considerable  callus  thrown  out  around  lower  end  of 
upper  fragment,  with  an  attempt  at  union.  Lateral  view.  (/. 
B.  Murphy.') 


DELAYED   UNION   AND   UNUNITED   FRACTURES.    219 


Fig.  99. — A,  same  as  Fig.  98.  Illustrating  intramedullary 
dowel  ten  weeks  after  application.  Antero-posterior  view.  B, 
same  as  Figs.  98  and  99^4.  Eight  months  after  the  application 
of  intramedullary  dowel  in  the  tibia.  No  attention  given  to 
fibula.  Shows  union  of  both  bones.  Antero-posterior  view. 
(/.  B.  Murphy.) 


220  MODERX    OPERATIVE   BOXE    SURGERY. 

nutrient  artery;  where  the  nutrient  artery  is  in- 
volved; under  separation  of  the  fractured  surface, 
either  from  overlapping*  or  from  retraction,  as  in 
fractures  of  the  patella ;  extensive  necrosis  as  is 
sometimes  found  in  compound  fractures,  due  to 
extensive  trauma  of  the  soft  parts,  with  infection 
following". 

The  constitutional  causes  are  specific  fevers 
occurring  during'  the  process  of  repair.  If  the 
fever  commences  about  the  time  of  the  injury  it  is 
especially  apt  to  lead  to  nonunion.  Delirium  tre- 
mens and  the  resulting  disturbances  may  deter  or 
even  cause  nonunion ;  especially  is  this  true  when 
there  are   degenerative   changes   in   the  kidneys. 

In  rickets,  as  a  rule,  normal  ossification  does 
not  take  place,  notwithstanding  the  abundance  of 
callus  thrown  out.  General  debility,  anemia,  scurvy, 
gout,  old  age,  and  paralysis  are  said  to  have  some 
influence  upon  the  repair  of  fractures  or  the  re- 
generation of  bone. 

The  direct  cause  is  a  diminution  or  cessation 
of  osteogenetic  activity  in  the  ends  of  the  frag- 
ments. Unless  activity  of  the  bone-growing  ele- 
ments can  be  re-established,  a  permanent  nonunion 
will  exist.  There  may  be  some  defective  bone 
disease  existing,  such  as  osteomyelitis,  or  sarcoma. 

The  efficiency  of  the  intramedullary  dowel  as 
an  internal  splint  under  certain  conditions  in  the 
treatment  of  ununited  fractures,  or  in  pseudo- 
arthroses of  the  long  bone,  where  the  surgeon 
anticipates  trouble  in  holding  the  bones  in  position, 
is   far   superior   to   the    inlay  in   holding   the   frag- 


DELAYED   UNION   AND   UNUNITED   FRACTURES.    221 


Fig.  100. — Same  as  Figs.  98  and  99,  A  and  B.  One  year 
after  placing  of  intramedullary  dowel  in  tibia.  Perfect  union 
of  both  bones.     (/.  B.  Murphy.) 


222  MODERX    OPERATIVE   BOXE   SURGERY. 

ments  in  alignment.  On  the  other  hand,  if  the 
bone  is  easily  held  in  place,  the  inlay  graft  is 
preferable,  for,  as  previously  stated,  the  inlay 
transplant  carries  with  it  greater  osteogenetic 
power  than  does  the  intramedullary  dowel,  because 
it  is  applied  with  the  periosteum,  compact  bone, 
endosteum,  and  marrow  intact,  and  because  it  con- 
tacts with  tissue  of  like  consistency.  Under  such 
environments  the  transplant  lives  and  grafts  much 
more  readily  than  it  does  under  other  circum- 
stances. 

In  either  ununited  fractures  or  pseudo-arthroses 
the  length  and  size  of  the  transplant  are  governed 
bv  the  impairment  of  the  osteogenetic  power,  the 
extent  of  comminution,  the  age  of  the  fracture, 
the  size  and  length  of  the  bone,  and  the  amount 
of  osteoporosis  in  the  fractured  ends. 

In  order  to  achieve  continued  success,  the 
transplant  must  extend  beyond  the  eburnated  area, 
and  at  least  i"  into  healthy  bone  in  both  frag- 
ments. The  recipient  bone  or  graft-bed  should 
always  be  prepared  first  in  all  cases,  whether  re- 
cent or  ununited  fracture. 

The  locations  where  ununited  fract'rtres  are 
most  likely  to  follow  are  fractures  of  the  neck  of 
the  femur,  greater  trochanter,  and  lower  third  of 
the  femur;  middle  of  the  shaft  of  the  humerus, 
patella,  bones  of  the  leg,  and  olecranon  process. 

In  nonunion  of  fractures  of  the  long  bone,  a 
free  longitudinal  incision  is  made  over  the  seat 
of  nonunion.  The  ends  of  the  bones  are  released 
from    their    fibrous    union   with    the    author's    bone 


DELAYED    UNION   AND   UNUNITED   FRACTURES.    223 


Fig.  101. — Pott's  fracture  six  months  after  accident,  display- 
ing wire  used  in  fastening  fracture  of  fibula,  together  with  bony 
union  between  fragments  of  fibula.  Also  showing  imperfect 
reduction  of  articulating  surfaces  ©f  astragalus  and  tibia.  Re- 
sult, bad  deformity. 


224 


MODERN    OPERATIVE    BOXE    SURGERY. 


Fig.  102. — Upper  portion  of  leg  showing  almost  entire  de- 
struction of  upper  half  of  tibia,  due  to  acute  osteomyelitis,  in  a 
boy  10  years  of  age.  Also  illustrating  an  ordinary  6-penny  nail 
driven  through  the  upper  portion  of  fibula  into  head  of  tibia. 


DELAYED   UNION   AND   UNUNITED   FRACTURES.    225 


Fig.  103. — Same  as  Fig.  102.  Shows  12-inch  transplant  in 
position  three  months  after  application,  with  perfect  bony  union 
resulting,  and  good  alignment  of  parts.  Nail  still  in  position 
without  change  in  surrounding  bone. 


15 


226  MODERN    OPERATIVE   BONE    SURGERY. 

elevating  spoons  or  skids  (Fig.  48).  These  in- 
struments are  almost  indispensable  in  releasing  the 
fragments  of  ununited  fractures  of  long  standing; 
with  them  the  fibrous  bands  are  easily  broken  up, 
and  they  greatly  lessen  the  amount  of  trauma, 
otherwise  unpreventable,  which  is  very  essential. 
After  the  fragment  ends  have  been  released,  they 
are  freshened  with  the  author's  motor  burr.  The 
author's  electric  single  or  twin  saws  are  used  to 
prepare  the  bed  for  the  inlay.  If  one  is  not 
accustomed  to  using  the  electric  motor  single  saw 
in  preparing  the  bed,  it  is  well  to  use  the  parallel 
or  twin  saws. 

The  plug  of  sclerosed  bone  in  the  medullary 
canal  of  each  fragment  should  always  be  removed 
whether  inlay  or  intramedullary  dowel  is  used. 
The  diameter  of  the  inlay  is  largely  governed  by 
the  size  of  the  bone,  as  stated  above.  In  the 
adult  femur,  an  inlay  at  least  %"  in  diameter, 
should  be  used;  the  length  of  the  inlay  depends 
upon  the  amount  of  sclerosis  or  eburnation.  After 
the  bed  has  been  thoroughly  prepared,  the  same 
twin  or  parallel  saws  are  used  to  remove  the 
graft  from  above  or  below  the  injury,  or  from 
the   shaft  of  the   tibia. 

In  removing  the  graft,  the  ends  of  the  graft 
are  cut  through  by  means  of  several  drill-holes, 
and  finally  released  by  a  chisel  and  hammer.  It 
is  not  advisable  to  release  the  ends  of  the  graft 
by  the  use  of  the  circular  saw,  because  of  the 
liability  of  cutting  beyond  the  side  of  the  graft, 
which   would  weaken  the   donor  bone,   from   which 


DELAYED   UNION    AND   UNUNITED   FRACTURES.    227 


Fig.  104. — A,  showing  absence  of  a  part  of  lower  portion  of 
tibia,  due  to  osteomyelitis  and  hypertrophy  of  the  fibula,  with 
marked  evidence  of  Wolff's  law.  B,  same  as  A,  with  intra- 
medullary dowel  in  position.     (/.  B.  Murphy.) 


228  MODERN   OPERATIVE   BONE   SURGERY. 

a  fracture  may  follow.  The  graft  is  now  removed 
from  its  original  bed  by  the  author's  graft-re- 
taining forceps  (Fig.  44),  and  placed  in  the 
groove  previously  prepared.  One-eighth-inch  holes 
are  now  made  from  side  to  side  through  the  re- 
cipient bone  and  the  graft — two  holes  in  the  upper 
and  two  in  the  lower  fragment — into  which  bone- 
pegs   are   driven  to  hold  the   graft  in  position. 

The  wound  is  closed  layer  by  layer  with  ab- 
sorbable sutures;  the  skin  is  closed  with  plain  cat- 
gut, subcuticular  stitch.  Plain  gauze  is  applied, 
and  the  limb  is  immobilized  by  a  plaster-of-Paris 
cast  dressing. 

If  it  is  a  fracture  of  the  neck  of  the  femur 
the  cast  should  extend  from  the  toes  to  the  axillae, 
or  at  least  above  the  waist-line.  Complete  immob- 
ilization is  all-essential  in  all  bone  transplantations. 

If  it  is  necessary  to  use  the  intramedullary 
dowel,  on  account  of  difficulty  in  holding  the  frag- 
ments in  alignment,  the  method  of  procedure 
would  be  as  follows:  Place  an  autogenous  bone- 
graft  in  the  medullary  canal  of  the  injured  bone, 
across  the  nonunion  well  into  each  fragment.  In 
such  cases,  the  intramedullary  transplant  is  ap- 
plicable and  gives  excellent  results.  It  may  also 
be  advisable  to  use  the  intramedullary  dowel  in 
ununited  fractures  of  the  shaft  of  long  single 
bones,  such  as  the  humerus  and  femur,  where  it 
is  difficult  to  hold  them  in  alignment;  in  parallel 
bones  where  both  bones  are  ununited,  as  the  radius 
and  ulna,  and  the  tibia  and  fibula;  where  the  ends 
of  the   fragments   are   not   too   badly  destroyed   by 


DELAYED   UNION  AND  UNUNITED   FRACTURES.   229 

comminution,  scleroses  or  absorption;  where  the 
medullary  canal  can  be  cleared  of  the  deposit  of 
hard  brittle  callus  without  breaking  or  destroying 
the  circle  of  original  compact  bone  of  the  shaft. 

The  essentials  to  the  grafting  process  are: 
the  re-establishment  of  the  medullary  canal,  in  the 
fragments  into  healthy  marrow,  and  bone-to-bone 
apposition  of  the  transplant  to  the  walls  of  the 
medullary  canal  of  each  fragment,  as  well  as 
staple  immobilization  during. the  necessary  time  for 
union. 


CHAPTER  XXXII. 

The  Application  of  the  Intramedullary 
Transplant  in  Ununited  Fractures. 

The  medullary  transplant  is  applied  as  fol- 
lows: The  field  of  operation  having  been  thor- 
oughly prepared,  a  free  incision  is  made  over  the 
nonunion.  The  ends  of  the  bone  are  cleared  of 
the  interposing  fibrous  tissue,  and  freshened  with 
as  little  destruction  of  the  fragments  as  possible. 
The  author's  electric  drill  and  reamer  are  used  to 
remove  the  eburnation  and  brittle  bony  formation 
from  the  canal  of  each  fragment.  Great  care 
should  be  taken  when  removing  this  eburnation 
not  to  split  or  break  the  brittle  ends  of  the  frag- 
ments. Should  the  size  of  the  graft  be  V2"  in 
diameter,  a  %"  chisel  is  used  to  square  the  hole 
or  canal  for  the  reception  of  the  dowel  transplant. 
The  transplant  is  removed  from  above  or  below 
the  fragments,  or  from  the  crest  of  the  tibia  with 
the  author's  parallel  or  single  saws.  If  the  single 
saw  is  used,  the  caliper  knives  are  brought  into 
play,  and  accurate  measurements  are  made  of  the 
canal,  and  the  transplant  is  laid  out  on  the  crest 
of  the  tibia  with  the  caliper  knives,  which  will 
give  a  dowel  the  exact  size  of  the  canal  prepared, 
if  the  lines  of  the  caliper  knives  are  accurately 
followed.  It  cannot  be  too  forcibly  impressed  that 
the  transplant  must  be  long  enough  to  reach  well 
(230) 


THE   INTRAMEDULLARY   TRAXSPLAXT.  231 

into  the  healthy  bone  of  each  fragment,  bridging 
the  entire  sclerosed  area  with  fresh  living  bone. 
The  periosteum  must  always  be  removed  from  the 
transplant  when  used  as  an  intramedullary  dowel, 
as  it  is  completely  buried,  and  the  periosteum 
would  act  as  an  interposing  tissue,  preventing 
bony  union  between  the  transplant  and   its  host. 

The  transplant  being  introduced  into  the  me- 
dullary canal  of  each  fragment,  across  the  defect, 
and  the  fragments  having  been  placed  in  good 
alignment,  the  wound  is  closed  in  layers  with  ab- 
sorbable suture;  the  skin  is  closed  with  subcuticu- 
lar stitch,  plain  catgut  suture.  Complete  immob- 
ilization is  accomplished  by  the  application  of  a 
plaster-of-Paris  dressing,  extending  up  over  the 
well  joint  above,  and  to  the  joint  below,  thereby 
immobilizing  both  the  joints  above  and  below.  The 
cast  is  allowed  to  remain  from  five  to  six  weeks. 
A  window  is  cut  in  the  cast  to  allow  dressing  of 
the  wound;  this  window  is  cut  before  the  plaster 
is  thoroughly  dry.  The  wound  should  be  dressed 
eight  to  ten  days  after  operation,  and  as  fre- 
quently thereafter   as   may   be    required. 


CHAPTER  XXXIII. 

Club-foot. 

Autoplastic  remodeling  of  club-foot  must 
necessarily  take  into  consideration  the  age  of  the 
patient,  and  the  degree  and  type  of  the  deformity. 

In  talipes  equinovarus  the  outer  side  of  the 
foot  is  convexed,  and  the  surface  considerably  ex- 
tended; the  removal  of  a  V-shaped  piece  both 
from  the  soft  parts  and  from  the  os  calcis  and 
cuboid  bones  (as  shown  in  Fig.  105)  allows  the 
foot  to  be  straightened  and  fixed  in  such  position 
with   little   effort    (Fig.    106). 

The  technic  of  the  operative  treatment,  as  de- 
vised by  the  author,  for  dealing  with  this  most 
common   variety   of   talipes,    is    as    follows: 

The  deformed  foot  and  lower  portion  of  the 
leg,  having  been  prepared  for  operation,  the  equi- 
nos  is  first  corrected  by  tenotomizing  the  tendo 
Achillis  to  enable  the  operator  to  force  the  foot 
into  dorsal  flexion  on  the  leg.  A  tenotome  is 
thrust  through  the  skin  about  1"  above  the  inser- 
tion of  the  tendo  Achillis  into  the  os  calcis  with 
the  blade  parallel,  and  just  anterior  to  the  tendon, 
the  cutting  edge  of  the  tenotome  is  turned  pos- 
teriorly, and  the  tendon  is  divided  from  before, 
backwards.  Care  must  be  taken  to  also  divide  the 
planteris  tendon.  The  division  is  very  perceptible 
in  the  sudden  giving  away  of  the  resistance  to  the 
(232) 


CLUB-FOOT. 


233 


dorsal  flexion  of  the  foot.  A  tourniquet  is  never 
employed  in  any  kind  of  bone  work,  for  reasons 
previously  given.  A  diamond-shaped  incision  is 
now  made,  beginning  %"  in  a  child  and   i"  in  an 


Fig.  105. — -Illustrating  removal  of  a  wedge-shaped  piece 
taken  from  the  outer  and  convex  surface  of  the  foot  in  a 
marked  case  of  talipes  equinovarus,  including  the  soft  parts; 
and  a  wedge-shaped  piece  from  the  posterior  portion  of  the 
cuboid  bone ;  and  a  wedge-shaped  piece  from  the  os  calcis. 
Used  in  all  patients  over  two  years  old. 


Fig.  106. — Appearance  of  the  foot  after  a  wedge-shaped 
piece  had  been  removed  from  the  outer  surface  in  an  exagger- 
ated case  of  talipes  equinovarus.  The  foot  has  been  straight- 
ened. Also  shows  dowel  in  position  to  give  rigidity  and  firm- 
ness to  the  bones  of  the  foot  in  their  new  relations  until  bony 
union  takes  place. 

adult,  anterior  to,  and  level  with,  the  external 
condyle;  the  anterior  incision  extending  forward 
and    downward   to    the    junction    outermost    of   the 


234  MODERN    OPERATIVE   BONE    SURGERY. 

cuboid  and  fifth  metatarsal  bones,  then  backward 
and  inward  to  almost  the  center  of  the  sole  of  the 
foot,  laterally.  The  posterior  incision  starts  in 
common  with  anterior,  and  extends  downward  and 
backward,  at  the  junction  of  the  outermost  por- 
tion of  the  foot.  It  should  be  in  line  with  the 
external  malleolus,  or  with  the  shaft  of  the  fibula; 
then  the  incision  passes  anterior  and  inward,  meet- 
ing the  anterior  incision  near  the  middle,  laterally, 
of  the  sole  of  the  foot.  These  incisions  extend 
into  the  bone,  posterior  to  the  os  calcis,  and  an- 
terior to  the  cuboid.  The  soft  tissue  is  now  re- 
moved en  masse.  The  motor  saw  is  now  used  to 
remove  a  V-shaped  piece  from  the  os  calcis  and 
cuboid  bones,  the  apex  of  the  V  meeting  near  the 
junction  of  the  os  calcis,  scaphoid  and  cuboid  bones. 
Two  slanting  holes  are  now  made  in  the  os  cal- 
cis and  cuboid,  opposite  to  each  other  on  the  an- 
terior surface,  with  the  %4"  motor  drill.  Two 
similar  holes  are  made  in  the  posterior  portion  of 
the  bones.  The  sharp  edges  of  the  bone  are  re- 
moved from  around  these  holes,  so  that  they  will 
not  sever  the  kangaroo  tendon,  which  is  tied  tightly 
around  them  to  hold  the  bones  intact  until  bony 
union  takes  place.  The  connective  tissue  is  brought 
together  by  a  continuous  chromic  catgut  suture, 
which,  in  addition  to  the  kangaroo  tendon,  assures 
continued  contact  of  the  new  surface  of  the  os 
calcis  and  cuboid  bones.  The  skin  is  closed  with 
a  plain  catgut  subcuticular  stitch.  The  wound  is 
dressed  with  gauze ;  the  foot  and  leg  are  placed 
in  a  plaster-of-Paris  fixation-dressing,  which  is   al- 


CLUB-FOOT.  235 

lowed  to  slightly  overcorrect  the  deformity,  and  to 
remain  for  six  weeks.  This  operation  assures 
against  the  recurrence  of  deformity,  gives  a 
good  shaped  foot,  removes  the  bulky  mass  of  skin 
and  connective  tissue  which  naturally  forms  on  the 
outer  surface  of  the  foot  when  the  deformity  is 
straightened   by   other   methods. 


CHAPTER  XXXIV. 
Spina  Bifida. 

The  osteoplastic  transplant  is  used  successfully 
in  closing  the  defects  in  spina  bifida  and  in  other 
congenital  defects  and  deformities  of  the  various 
bones  of  the  body.  Several  cases  have  been  re- 
ported in  which  the  reoccurrence  of  spina  bifida, 
or  of  the  spinal  hernia,  was  continuously  con- 
trolled. The  operation  should  be  performed  dur- 
ing the  first  or  second  year  of  the  child's  life,  or, 
in  other  words,  as  soon  as  the  child  can  stand 
such  operation. 

For  operation  the  patient  is  placed  in  the  ven- 
tral position,  to  prevent  sudden  drainage .  of  the 
cerebrospinal  fluid  from  the  brain  on  puncture  of 
the  sac.  The  head  is  placed  lower  than  the  but- 
tocks; the  body  reclined  at  an  angle  of  35°.  The 
sac  is  exposed  by  a  curved  transverse  incision 
above  the  tumor ;  the  tumor  is  separated  from  the 
surrounding  tissues,  down  to  the  defect  in  the 
bone;  it  is  punctured  and  allowed  to  gradually 
subside  or  collapse,  and  the  sac  is  then  replaced 
within  the  cleft.  The  periosteum  is  dissected  back 
from  the  edge  of  the  cleft;  the  bone  is  freshened, 
and  is  now  ready  for  the  reception  of  the  trans- 
plant. The  caliper  knives  are  used  in  measuring 
the  opening,  and  for  shaping  the  transplant,  which 
(236) 


SPINA   BIFIDA.  237 

may  be  obtained  from  the  scapula,  the  upper  por- 
tion of  the  tibia,  or  ribs  of  the  child. 

In  removing  the  transplant,  an  extra  amount 
of  periosteum  should  remain  on  the  graft,  so  that 
the  transplant  ma}7-  be  easily  fastened  in  position 
by  sewing  the  free  edge  of  the  periosteum  to  the 
surrounding  tissue.  The  wound  is  closed  as  usual, 
and  dressed  with  plain  gauze,  fastened  snugly  to 
the  part  with  oxide  of  zinc  adhesive  plaster. 


CHAPTER  XXXV. 

Autogenous   Bone-grafts   Used  in   Replacing 

Shafts   and   Articulating   Bone   Removed 

on  Account  of  Mutilation  and 

Disease. 

In  defects  of  long  bones  (Fig.  109),  where  the 
articulating  surface  is  involved,  and  a  portion  of 
the  shaft  has  been  destroyed  or  removed  on  ac- 
count of  mutilating  injuries,  osteomyelitis  or  osteo- 
sarcoma, or  a  portion  of  the  shaft  and  epiphyses 
resected,  osteoplastic  repair  for  deficiencies  or  de- 
fects is  beyond  the  experimental  stage.  Cases  in 
which  the  entire  shaft  and  one  of  the  articulating 
ends  of  the  bone  have  been  removed,  on  account 
of  disease  or  injury,  have  been  successfully  re- 
placed by  the  transplantation  of  bone  removed 
from  the  tibia  or  fibula.  The  shoulder  being  an 
enarthrodial  joint  with  a  large,  loose  capsule, 
offers  the  most  favorable  opportunity  for  joint- 
repair. 

The  defect  is  exposed  by  Langenbeck's  incision. 
The  fragment  end  of  the  humerus  is  prepared  for 
the  reception  of  the  transplant.  Should  the  graft 
be  removed  from  the  upper  part  of  the  fibula,  the 
end  that  is  placed  in  the  medullary  canal  of  the 
humerus  is  stripped  of  its  periosteum.  The  upper 
free  end  is  inserted  into  the  glenoid  cavity,  and 
the  capsule  of  the  joint  sutured  around  it.  The 
(238) 


AUTOGENOUS    BONE-GRAFTS. 


239 


Fig.  107. — Upper  half  of  humerus  enlarged,  enlargement 
gradually  diminishing  to  normal  size,  with  a  peculiar  exostosis 
springing  from  near  the  head.  Female,  aged  15 ;  diagnosis, 
malignant. 


240 


MODERN    OPERATIVE   BONE    SURGERY. 


Fig.  108. — Case  of  osteitis  fibrosa  cystica  of  the  lower  ar- 
ticulating surface  of  the  radius,  in  girl  11  years  of  age.  (/.  B. 
Murphy.) 


AUTOGENOUS    BONE-GRAFTS. 


241 


Fig.  109. — Osteitis  fibrosa  cystica  involving  upper  extremity 
of  femur  for  about  one-third  distance.  The  articulating  sur- 
face and  head  appear  to  be  intact.     (/.  B.  Murphy.) 


10 


242 


MODERN    OPERATIVE    BONE    SURGERY. 


Fig.  110. — Same  as  Fig.  109.  After  removal  of  diseased 
bone,  including  articulating  surface.  A  transplant  7l/2  inches 
long  was  removed  from  the  opposite  tibia;  the  lower  end  was 
driven  into  the  medullary  canal  of  the  humerus  fragment,  and 
held  in  place  with  a  small  wire  nail.  The  upper  end  of  the 
transplant  was  placed  in  the  glenoid  cavity,  and  the  capsule 
sutured  around  it.     (/.  B.  Murphy.) 


AUTOGENOUS    BONE-GRAFTS. 


243 


Fig.  111. — Same  as  Fig.  109.  Nine  months  after  operation. 
The  upper  end  of  the  humerus  has  been  regenerated  to  a  con- 
siderable extent,  including  the  tuberosities  and  the  articulating 
surface.  The  white  line  a  little  to  the  right  of  the  central  axis 
of  the  new  portion  of  the  shaft  represents  the  periosteum, 
which  was  left  on  the  transplant.     (/.  B.  Murphy.) 


244  MODERN    OPERATIVE   BONE    SURGERY. 

muscular  attachments  and  muscles  are  sutured  in 
place,  and  the  wound  is  closed  in  layers;  the  skin 
is   closed  with   subcuticular   stitch. 

In  a  case  reported  by  the  late  Dr.  John  B. 
Murphy  (Figs.  109  and  no),  resection  of  the 
upper  part  of  the  humerus,  including  the  epiphyses 
was  performed  for  osteitis  fibrosa  cystica  in  a 
girl  10  years  old.  A  transplant  from  the  crest  of 
the  tibia  7%"  long,  %"  wide,  and  %"  thick,  was 
removed,  and  transplanted  into  the  defect.  The 
end  of  the  graft  that  was  driven  into  the  upper 
end  of  the  fragment  of  the  shaft  was  denuded  of 
its  periosteum,  and  the  upper  end  of  the  graft 
was  inserted  in  the  glenoid  cavity,  and  the  cap- 
sule of  the  joint  sutured  around  it.  The  wound 
is  closed  as  usual,  and  the  arm  dressed  in  abduc- 
tion at  right  angle  with  the  body,  with  weight  ex- 
tension. At  the  end  of  five  weeks  the  transplant 
had  grafted  to  the  humerus;  there  was  good 
motion  at  the  shoulder- joint  up  to  right  angle 
(Fig.  in)  in  abduction.  The  inferior  epiphyses 
of  the  ulna,  with  its  articulating  surface,  and  a 
portion  of  the  shaft,  were  resected  by  Dr.  Blood- 
good,  on  account  of  osteosarcoma,  and  were  re- 
placed by  a  transplant  removed  from  the  ulna 
above  the  resection.  The  patient  recovered  in 
three  months,  with  a  good  motion  of  the  wrist- 
joint. 


CHAPTER  XXXVI. 

Remodeling  or  Repairing  the  Nose. 

Remodeling  of  the  bridge  of  the  nose  with 
osteoplastic  transplantation  to  remedy  the  defor- 
mity produced  by  destruction  of  the  bony  frame- 
work, by  injury  or  disease,  has  been  employed 
with  success  by  Drs.  Lothrop,  Carter  and  others. 
In  the  method  of  operation  used  by  Lothrop,  the 
bone-transplantation  is  obtained  from  the  verte- 
bral border  of  the  scapula.  It  furnishes  a  trans- 
plant already  shaped,  except  in  length  and  width, 
which  are  obtained  by  the  use  of  the  caliper 
knives;  it  is  covered  with  periosteum  on  both  sides 
and  top;  it  is  much  more  likely,  when  grafted  in 
position,  to  retain  its  vitality  and  shape  in  its  new 
relations  without  becoming  absorbed,  or  overgrow- 
ing, than  grafts  received  from  other  bones  of  the 
body. 

Lothrop  makes  an  incision  in  the  under  surface 
of  the  tip  of  the  nose,  and  a  subcutaneous  canal 
extending  up  to  the  nasal  bone.  The  periosteum 
on  the  nasal  bone  is  elevated,  along  the  bridge  of 
the  nose,  to  the  frontal  bone.  The  nasal  bone  is 
dressed  down  until  the  transplant  fits.  The  scap- 
ula graft  is  then  fitted  to  the  length,  and  placed 
with  the  fresh-cut  surface  next  to  the  nasal  bone. 
It  is  placed  into  the  canal  prepared  for  it  beneath 
the  periosteum,   and   is   forced   in   until   the   frontal 

(245) 


246  MODERN    OPERATIVE   BONE    SURGERY. 

bone  is  reached.  A  dressing  is  applied  to  the 
nose  whereby  a  slight  amount  of  pressure  is  made 
upon  the  transplant  to  hold  it  in  apposition  with 
the  frontal  bone.  This  dressing  should  be  re- 
moved at  intervals,  whenever  soiled.  At  the  end 
of  four  weeks  the  transplant  should  be  grafted  to 
the  nasal  bone.  Great  care  should  be  exerted  dur- 
ing the  above  time  to  avoid  any  cause  of  motion 
of  'the  transplant. 

In  defects  of  the  skull  various  methods  have 
been  devised  for  their  correction.  Dr.  Ropke  has 
suggested  that  a  graft  be  removed  from  the  wing 
of  the  scapula,  as  it  affords  an  excellent  graft  for 
such  purpose,  because  of  its  thinness,  and  also 
that   it   is   covered   on   both   sides   with   periosteum. 

The  technic  used  for  inserting  bone-grafts  for 
skull  defects  is  as  follows:  After  shaving  and 
thoroughly  preparing  the  scalp,  an  oval  incision 
is  made  at  least  half  an  inch  larger  on  all  sides 
than  the  opening  in  the  skull.  In  separating  the 
scalp  and  the  dura  great  caution  must  be  used. 
In  case  the  dura  is  thickened  and  adhered  to  the 
brain  proper,  it  should  be  dissected  away,  provid- 
ing the  adhesions  have  produced  brain  symptoms. 
A  flat  piece  of  steel  is  now  placed  between  the 
skull  and  dura,  to  protect  the  underlying  brain, 
and  a  sharp  chisel  or  osteotome  is  used  to  freshen 
the  edges,  and  to  cut  away  the  thin  ring  back  to 
the  normal  thickness  of  the  skull,  and  shape  the 
opening  ready  for  the  reception  of  the  graft.  The 
edges  are  bevelled  to  prevent  the  graft  from  caus- 
ing undue  pressure  on  the  brain.     The  dimensions 


REMODELING   OR   REPAIRING   THE   XOSE.  247 

of  the  opening  are  now  carefully  taken  with  the 
caliper  knives,  and  a  pattern  is  made  of  oil  paper 
or  sheet-lead  to  fit  the  opening  of  the  skull.  By 
the  aid  of  the  pattern  and  caliper  knives  the  exact 
size  and  contour  of  the  graft  is  outlined  on  the 
surface  of  the  periosteum.  The  graft  is  removed 
with  the  author's  %."  motor  saw  from  the  wing  of 
the  scapula,  or  from  the  upper  and  anterior  por- 
tion of  the  shaft  of  the  tibia.  The  edges  of  the 
graft  should  be  bevelled  the  same  as  the  edges  of 
the  bone  in  the  opening  of  the  skull.  An  abund- 
ance of  periosteum  should  be  removed  with  the 
graft.  In  preparing  the  bed  for  the  graft,  should 
the  dura  be  lacerated,  a  thin  sheet  of  collodium 
should  be  applied  just  before  the  transplant  is  put 
in  place.  A  few  stitches  of  Xo.  I  chromic  gut 
are  used  to  sew  together  the  periosteum  of  the 
graft  and  skull,  and  the  scalp  is  closed  in  the 
usual  manner  with  plain  gut.  A  plain  gauze 
dressing  is  snugly  applied,  and  retained  in  position 
with  adhesive  plaster. 


CHAPTER  XXXVII. 

Tuberculosis  of  the  Vertebrae. 

Synonyms  for  this  disease  are:  Pott's  Disease, 
Spondylitis,  Caries  of  the  Spine,  Hump-back,  An- 
gular Curvature  of  the  Spine,  and  Kyphosis. 

The  name  Pott's  disease  is  given  to  a  tuber- 
culous infection  of  the  vertebra,  attacking  in  most 
cases  the  bodies  of  the  vertebrae,  rarely  the  spin- 
ous processes  or  the  laminae.  It  derives  its  name 
from  an  English  surgeon,  Percival  Pott,  by  whom 
it  was  first  described  in  I//6.  It  occurs  oftener 
in  the  male  than  it  does  in  the  female,  and  is 
one  of  the  most  common  tubercular  infections  of 
bone. 

The  location  most  commonly  affected  is  the 
lower  portion  of  the  dorsal,  or  upper  portion  of 
the  lumbar  regions.  However,  it  may  occur  in 
any   part   of   the   spinal   column. 

The  etiology  of  tuberculosis  of  the  spine  is  the 
susceptibility  or  predisposition  of  the  individual 
suffering  with  such  disease,  for  the  tubercular 
bacilli  are  omnipresent  in  the  body,  and  the  only 
reason  that  all  human  beings  do  not  suffer  from 
tuberculosis  is  that  they  are  not  susceptible,  or 
that  the  soil   is   not   fertile   for   its   development. 

Tuberculosis    of    the    vertebra,     as     a    rule,     is 
secondary  to   a   tubercular   focus    from    some   other 
part  of  the  body,   such   as  bronchial   or   mesenteric 
(248) 


TUBERCULOSIS    OF   THE   VERTEBRAE.  249 

lymph  nodes,  etc.  The  tubercular  bacillus  having 
obtained  access  to  the  body  of  the  vertebra,  which 
is  composed  of  spongy  consistency,  causes  the  for- 
mation of  miliary  tubercules.  The  tubercules  en- 
large, become  caseous  in  the  center,  and,  by  fusion 
of  the  caseous  area,  an  area  of  softening  of  con- 
siderable size  is  produced.  The  destruction  con- 
tinues until  the  entire  body  of  the  vertebra  is 
destroyed,  after  which  it  spreads  to  other  vertebra, 
unless  prevented  by  fixation. 

It  is  primarily  a  disease  of  middle  childhood, 
but  it  may  occur  at  any  age.  About  62  per  cent, 
of  all  cases  occur  before  the  age  of  16,  only  11 
per  cent,   occurring  after  the  age  of  25. 

The  pathological  changes  that  occur  take  place 
as  a  rule  in  the  spongy  tissues  of  one  or  more 
of  the  vertebral  bodies,  usually  at  the  anterior 
portion,  and  more  generally  near  the  articular  car- 
tilage than  elsewhere,  which  is  termed  spondylitis- 
superficialis,  or,  more  commonly  speaking,  a  super- 
ficial infection  of  the  front  of  the  vertebral  col- 
umn. The  lamina  and  spinal  processes  are  rarely 
attacked;  however,  this  occasionally  occurs. 

The  vertebral  column  is  a  weight-bearing  struc- 
ture, and  the  softening  of  the  vertebral  body  is 
apt  to  result  in  a  collapse  of  the  framework,  or 
column,  due  to  the  superincumbent  weight.  This 
causes  the  upper  portion  of  the  column  to  fall  for- 
ward and  form  a  more  or  less  sharp  backward 
projection,  depending  upon  the  number  of  vertebrse 
diseased.  The  deformity  is  known  as  the  ''ky- 
phosis."     A   multiple    focus  of   infection    rarely   oc- 


250  MODERN    OPERATIVE   BONE    SURGERY. 

curs.  By  the  weight  of  the  body  pressing  upon 
the  diseased  and  softened  vertebra  after  the  de- 
formity has  taken  place,  the  leverage  and  pressure 
which  contributes  to  the  cause  of  destruction  and 
deformity  continually  increase  unless  such  pres- 
sure  is   relieved. 

In  repair,  newly  formed  bone  takes  the  place 
of  the  tubercular-degenerated  bone,  and  ankylosis 
by  granular  formation  follows.  The  deformity  of 
the  chest  and  prominences  of  the  sternum  are  the 
results  of  the  upper  part  of  the  vertebral  column 
falling  forward.  In  severe  cases  the  lower  ribs 
come  below  the  crest  of  the  ilium;  a  change  in 
the  relation  of  viscera,  of  the  thorax  and  ab- 
domen, with  distortion  of  the  aorta,  are  caused  by 
the  changes  in  the  shape  of  the  chest.  The 
products  of  the  softening  caused  by  the  tuberculous 
degeneration  occasionally  find  their  way  out  under 
the  vertebral  fascia  into  the  surrounding  tissues. 
They  accumulate  back  of  the  pharynx  in  the  cer- 
vical region,  forming  a  retropharyngeal  tubercular 
cyst.  The  word  "abscess"  is  incorrect,  unless  we 
have  a  mixed  infection,  as  we  do  not  find  pus 
cells  in  a  purely  tubercular  fluid.  In  the  upper 
dorsal  region,  they  occur  most  often  in  the  media 
sternum,  or  pass  between  the  ribs,  finding  their 
way  around,  and  appearing  anterior  to  the  ster- 
num, rarefy  appearing  in  the  back  as  a  dorsal 
cyst.  In  the  lower  dorsal  or  lumbar  region  they 
follow  down  the  course  of  the  psoas  muscle,  ap- 
pearing in  the  groin,  or  Scarpa's  triangle,  as  a 
psoas    cyst;    or    in    some    cases    they    turn    around 


TUBERCULOSIS  OF  THE  VERTEBRA,      251 

the  rector  spinse  and  quadratus  lumborum  muscles, 
and  appear  in  the  loins  as  a  lumbar  cyst. 

In  a  certain  percentage  of  untreated  cases  the 
meninges  of  the  cord  become  involved  by  exten- 
sion of  the  disease;  especially  does  the  disease  ex- 
tend to  the  posterior  part  of  the  vertebral  body. 
The  inflammation  results  in  thickening,  and  pos- 
sibly pressure  on  the  cord.  As  another  cause,  we 
must  mention  embolism  of  the  spinal  vessels. 
Strangulation  of  the  cord  by  direct  pressure  by 
the  bone  of  the  vertebral  arch,  or  loosened  pieces 
of  bone,  may  also  cause  paralysis.  Should  menin- 
gitis occur,  and  subside,  it  leaves  behind  it  a  cer- 
tain amount  of  sclerosis.  Both  descending  and 
ascending   degeneration   may   follow. 

With  the  early  symptoms  come  fatigue,  loss  of 
flesh,  and  impairment  of  the  general  health.  Such 
children  begin  to  support  themselves  by  leaning 
against  any  available  object.  They  have  a  pecul- 
iar gait,  and  suffer  with  paroxysmal  abdominal 
pains.  The  stiffness  of  the  spine,  which  is  found 
early  in  these  cases,  causes  a  peculiar  attitude  and 
walk;  the  careful  manner  in  which  the  patient 
places  his  foot  while  walking  to  prevent  jarring, 
and  rises  from  a  chair  with  the  spine  held  stiff; 
in  all  movements,  unconsciously  protects  the  spine 
by  contracting  the  muscle  controlling  it.  Should 
the  patient  attempt  to  pick  up  anything  from  the 
ground  or  floor,  the  spine  is  not  flexed  as  is  nor- 
mally the  case,  but  the  hips  and  knees  are  bent, 
allowing  the  body  to  be  lowered,  while  the  spine 
is  held  erect. 


252  MODERN    OPERATIVE   BONE    SURGERY. 

In  tuberculosis  of  the  spine  we  may  have  both 
anteroposterior  and  lateral  displacement.  The  de- 
formity of  the  spine  and  the  attitude  of  the  pa- 
tient varies  according  to  the  region  of  the  spine 
affected.  Pain  is  rarely  entirely  absent,  and  is 
referred,  as  a  rule,  to  other  joints  or  parts  of  the 
body,  or  the  peripheral  ends  of  the  nerves  are  in- 
volved. Abdominal  pain  is  one  of  the  most  fre- 
quent symptoms  in  Pott's  disease,  and  is  the  most 
common  cause  of  a  mistaken  diagnosis.  Reflected 
pain  in  any  region  or  part  is  increased  by  acciden- 
tal jar.  In  the  acute  stage  we  may  have  a  high 
temperature.  In  advanced  cases  of  Pott's  disease 
the  most  characteristic  symptom  is  deformity, 
caused  by  the  collapse  of  one  or  more  vertebrae, 
resulting  in  a  backward  or  displacement  projec- 
tion of  the  spinous  processes.  The  deformity  in 
the  acute  stage  of  the  disease  is  generally  sharp 
and  angular,  but  later  in  the  disease  it  becomes 
more  marked  and  round  in  character.  In  the 
dorsal  region  the  deformity  is  most  conspicuous 
on  account  of  the  normal  backward  convexity  of 
the  spine  at  that  point,  and  is  least  noticeable  in 
the  cervical  and  lumbar  regions,  on  account  of 
the  forward  curves  of  the  vertebra  at  these  points. 

If  the  patient  is  a  child,  its  clothes  should  be 
entirely  removed;  if  an  adult,  the  entire  back 
should  be  exposed.  The  patient  should  then  be 
placed  upon  the  table,  or  upon  the  floor,  and  not  on 
a  soft  bed,  for  examination.  A  close  observation 
of  the  patient's  motion  on  rising  and  sitting  down 
should   be   made.      Stopping  and  turning  the  head, 


TUBERCULOSIS  OF  THE  VERTEBRA.      253 

stiffness  in  the  muscles  of  the  back  or  in  the  neck, 
on  motion,  should  be  regarded  as  a  prominent 
symptom.  In  the  lower  two-thirds  of  the  column 
the  most  common  symptom  relating  to  this  dis- 
ease is  observed  by  having  the  patient  lie  on  his 
face  and  passively  hyperextending  the  spine  while 
lifting  the  leg  from  the  floor  or  table.  If  the 
region  diseased  is  the  one  affected  by  the  motion, 
the  muscles  will  stand  out  like  whipcord  and  check 
the  hyperextension. 

In  cervical  Pott's,  the  motion  of  the  head 
should  be  carefully  observed;  any  restriction  of 
motion  is  suspicious.  Any  backward  deformity  es- 
tablishes the  fact  that  we  are  dealing  with  a 
destructive  disease  of  the  vertebra,  Pott's  disease 
being  the  most  frequent.  If  the  disease  is  allowed 
to  continue,  we  will  have  a  rise  of  temperature  at 
night;  later  on,  a  tubercular  cyst  in  a  character- 
istic situation,  and  possibly  the  existence  of  motor 
paralysis  affecting  the  parts  below  the  disease, 
with  increased  reflex,  all  of  which  strengthen  the 
establishment  of   diagnosis. 

After  one  or  more  vertebrae  have  been  de- 
stroyed, an  X-ray  photograph  should  be  taken, 
which  will  show  the  destruction  of  such  vertebrae. 
In  earlier  cases  a  negative  X-ray  cannot  be  ac- 
cepted as  positive  evidence  that  the  disease  does 
not  exist. 

The  prognosis  depends  largely  upon  the  early 
recognition  of  the  disease,  and  the  kind  of  treat- 
ment used,  and  is  favorable  with  the  following 
elements   existing:    the  absence  of  tuberculous  dis- 


254  MODERN    OPERATIVE   BONE    SURGERY. 

ease  of  the  joints,  good  inheritance,  fairly  good 
general  health,  the  absence  of  fever,  and  without 
excessive  pain  at  the  onset.  The  reverse  elements 
are   unfavorable. 

Nature  has  taught  us  that  immobilization  is 
the  prime  factor  in  arresting  tuberculosis  of  the 
bone.  Many  an  attempt  has  been  made  to  sub- 
stitute an  artificial  fixation  to  prevent  the  progress 
of  the  disease,  with  its  ravishing  results  of  crip- 
pling and  terribly  deforming  the  human  body. 

Early  treatment  is  essential  in  all  cases,  what- 
ever method  is  used,  and  whatever  elements  exist. 

In  the  conservative  brace  methods  we  have 
only  partial  means  to  accomplish  this  end.  In- 
creasing deformity  continues  to  develop  in  many 
cases,  until  complete  invalidism  follows,  and  finally 
the  patient  succumbs  to  this   dreadful   disease. 

In  using  the  brace  method  it  is  the  exception 
and  not  the  rule  for  caries  of  the  spine  to  be 
permanently  cured;  for  few  cases  have  actual  solid 
bony  union,  and  without  bony  union  it  cannot  be 
considered  a  cure.  These  joints,  like  other  joints 
of  the  body  attacked  by  tuberculosis,  where  only 
fibrous  union  takes  place,  are  always  liable  to  re- 
lapse. It  has  been  pointed  out  by  many  men 
dealing  with  tubercular  infection  of  the  bone  that 
it  is  very  essential  to  get  strong  bony  ankylosis  in 
order  to  arrest  and  cure  such  lesions,  where  actual 
bony  destruction  has  occurred.  This  rule  must  be 
even  more  strongly  applied  to  the  vertebral  joints 
of  the  spine  than  to  other  joints  of  the  body. 

Not  being  able  to  control  the  progress   of  this 


TUBERCULOSIS    OF   THE   VERTEBRAE.  255 

most  horrible  disease,  with  the  distorted  bodies 
constantly  in  evidence,  the  profession  has  been  for- 
cibly convinced  that  a  more  accurate  fixation  of 
the  tuberculous  spine  is  essential.  Appreciating 
the  leverage  action  of  these  vertebrae,  and  the 
failure  to  arrest  the  disease  by  external  appliances, 
recourse  was  had  to  actual  surgical  interference. 
Numerous  methods  were  tried  out.  as  wiring  the 
spinous  processes  with  silver  wire,  placing  a  metal 
bar  on  each  side  of  the  spinous  processes,  se- 
cured by  metal  or  silk  sutures.  The  above  at- 
tempts were  not  successful,  however.  In  the  last 
few  years  the  operative  treatment  of  Pott's  dis- 
ease has  gained  greatly  in  favor  with  the 
surgeons. 


CHAPTER  XXXVIII. 

Boxe-inlay  Grafts  in   the  Treatment 
of  Pott's  Disease. 

In  using  the  bone-inlay  graft  in  the  treatment 
of  tubercular  inflammation  of  the  vertebra  there 
are  three  recognized  methods  of  indirect  autoplas- 
tic immobilization  of  the  bodies  of  the  spinal  col- 
umn. The  success  of  these  methods  depends  upon 
anchoring  the  spinous  process  by  grafting  or  plac- 
ing a  transplant  of  living  bone  into  the  spines  of 
the  diseased  and  adjacent  living  vertebra,  thereby 
fusing,  as  it  were,  spines,  or  posterior  portions  of 
the  vertebra  into  a  continuous  bony  mass.  The 
methods  are  those  of  Don,  Albee  and  Hibbs. 

The  location  of  the  disease,  the  size  and  shape 
of  the  deformity,  and  the  age  of  the  patient,  gov- 
erns the  surgeon  in  selecting  such  method  that  is 
most  suitable   for   each   case. 

The  "Don"  method  (Fig.  112)  is  limited  to 
the  cervical  region,  because  of  the  anatomical 
shape,  size,  and  relation  of  the  spinous  processes 
of  that  location.  The  "Don"  operation  immobilizes 
the  cervical  vertebra  affected  with  tuberculosis  by 
bridging  it  with  a  transplant  of  living  bone  from 
the  spinous  process  of  the  vertebra  prominence, 
and  fastening  it  to  the  spine  of  the  axis. 

An  incision  is  made  over  the  cervical  region, 
exposing  the  spinous  process.  The  periosteum  is 
(256) 


BONE-INLAY   GRAFTS    IN    POTT'S    DISEASE.         257 

incised  and  dissected  back  from  the  spine  of  the 
seventh  cervical  vertebra  to  the  base  of  the 
second.  A  section  of  rib  is  removed,  long  enough 
to  reach  from  the  seventh  cervical  to  the  second 
cervical  spine.  The  periosteum  must  always  be 
removed  from  the  convex  surface.  An  opening  is 
made   in  the  broader   end   of   the   graft,   and  fitted 


Fig.  112. — Showing  the  '"Don"  operation,  bridging  the  cerv- 
ical vertebras  from  the  spine  of  the  axis  to  the  spine  of  the 
vertebral  prominence  with  an  autogenous  bone-transplant. 

over  the  spinous  process  of  the  vertebral  promi- 
nence. After  placing  the  section  of  the  rib  in  the 
gutter  with  the  convexity  forward,  the  lower  end 
is  adjusted  to  the  seventh  cervical  spine.  The 
upper  and  lower  ends  of  the  graft  having  pre- 
viously been  perforated,  are  now  firmly  fastened 
to  the  vertebrae  in  perfect  position,  the  neck  is 
held   in   proper   position,    so   that   it   can  be   placed 

17 


258  MODERN    OPERATIVE   BOXE    SURGERY. 

in  the  groove  at  the  base  of  the  spine  of  the 
axis,  and  sutured  with  kangaroo  tendon  to  the 
interspinous  ligament,  and  the  soft  parts  are  closed 
over  it. 

The  after-treatment  consists  of  rest  in  bed, 
with  sandbags  supporting  the  neck  on  either  side, 
until  the  patient  can  turn  the  head,  or  sit  up 
without  pain  and  discomfort.  The  use  of  mechan- 
ical support  is  counterindicated,  because  of  the 
danger  of  displacing  the  transplant  and  discom- 
fort to  the  patient.  By  the  transplant  grafting 
itself  to  the  spine  of  the  vertebra,  immobilization 
takes  place,  which  gives  relief  from  pain  and  mus- 
cular spasm,  and  finally  to  tubercular  disinte- 
gration. 

As  a  rule,  the  time  required  for  the  convales- 
cence  of   patient  varies   from   six   to   eight   weeks. 

In  the  technic  of  Dr.  Albee's  operation,  as 
modified  by  the  author,  a  sufficiently  long,  skin 
incision  is  made,  starting  above  the  diseased  area, 
and  curving  to  one  side  of  the  median  line,  and 
carried  back  to  the  median  line,  well  below  the 
affected  area,  thus  forming  a  semilunar  skin-flap, 
with  its  free  edge  well  away  from  the  median 
line,  to  avoid  having  the  skin  wound  directly  over 
the  bone  repair  graft,  thus  fortifying  the  grafted 
area,    should   any   skin   or    suture   infection   occur. 

Having  freed  the  skin-flap,  with  its  subcuta- 
neous structure,  the  tips  of  the  spinous  processes 
with  the  supraspinous  ligaments  are  exposed.  As 
there  are  no  important  vessels  in  this  region, 
hemorrhage   is   not   of  much   consequence.      If  need 


BOXE-IXLAY   GRAFTS    IX    POTT'S    DISEASE. 


259 


be  the  bleeding  points  are  picked  up  with  hemo- 
stats  and  tied,  but  a  hot  saline  compress  is  usu- 
ally sufficient  to  control  any  excessive  oozing,  and 
prevents    blood-clots    from    forming. 

The    supraspinous    ligament    is    split    over    the 
tips  of  the  spinous  processes  with  a  scalpel,  divid- 


Fig.  113. — Albee's  method  of  splitting  the  spine  of  the  ver- 
tebra perpendicularly,  producing  fracture  of  one  side  {A),  and 
showing  graft  (-B)  in  position. 

ing  them  into  equal  halves.  The  intraspinous  liga- 
ments are  also  split,  care  being  exercised  further 
not  to  cut  any  of  the  muscular  ligamentous  attach- 
ments to  these  spinous  processes.  Then,  with  a 
sharp  osteotome,  i}4"  wide,  the  spinous  processes 
are  split  to  a  depth  of  from  %"  to  %".  One- 
half  of  each  spinous  process  is  always  fractured 
completely  on  the  same  side  at  its  base,  and  set 
over    a    distance    varying    according    to    the    thick- 


260  MODERN    OPERATIVE   BONE    SURGERY. 

ness  of  the  graft  which  is  to  be  implanted.  All 
bleeding  should  be  controlled  before  the  wound  is 
closed. 

It  rests  with  the  operator  to  determine  the 
size  and  thickness  of  the  graft  to  be  used  in  each 
case,  taking  into  consideration  the  segment  of  the 
spine  to  be  grafted  and  the  amount  of  strain  the 
graft  must  endure.  In  general,  the  thickness  of 
the  graft  should  include  the  total  thickness  of  the 
tibial  cortex,  including  the  four  following  differ- 
ent tissues:  periosteum,  endosteum,  cortex,  and 
marrow   substance. 

The  graft-bed  once  prepared  presents  on  one 
side  of  the  gutter  the  incised  surface  of  the  un- 
broken halves  of  the  spinous  processes,  and  in  the 
interval  between  these  processes  are  the  cut  sur- 
faces of  the  halves  of  the  supraspinous  and  inter- 
spinals ligaments,  with  their  bone  attachments  un- 
disturbed. The  opposite  wall  of  this  gutter  is 
formed  by  the  incised  surfaces  of  the  fractured 
halves  of  the  spinous  processes,  with  their  portions 
of  supraspinous  and  interspinous  ligaments  undis- 
turbed, as  in  the  opposite  side  of  the  gutter.  The 
full  leverage  of  the  spinous  processes  as  posterior 
arms  of  vertebral  levers  has  been  largely  pre- 
served. 

In  this  connection  it  should  be  appreciated  that 
the  spine  is  made  up  of  a  distinct  number  of 
levers,  and  that  each  and  every  vertebra  is  an 
individual  lever,  with  its  fulcrum  at  the  lateral 
facets,  and  that  its  anterior  arm  is  the  vertebral 
body;  the  posterior   arm  is   the   spinous   process. 


BONE-INLAY    GRAFTS    IN    POTT'S    DISEASE.         261 

The  length  and  shape  of  the  required  graft  is 
determined  by  the  author's  caliper  knives  and  a 
piece  of  sheet  lead  or  a  flexible  probe  applied  to 
the  gutter-bed,  and  used  as  a  pattern  to  shape  the 
graft.  The  bed  is  covered  with  plain  gauze  until 
the  graft  has  been  removed  from  the  tibia. 

Removal  of  the  Graft.  With  the  patient  still 
lying  on  the  stomach,  the  leg  from  which  the 
graft  is  to  be  removed  is  raised  from  the  table, 
and  flexed  to  an  acute  angle  on  the  thigh,  which 
brings  the  anterior  portion  of  the  leg  in  good 
position  for  removal  of  the  graft.  A  generous 
skin  incision  is  made  along  the  anterointernal  sur- 
face of  the  tibia,  sufficiently  long  to  allow  a  free 
exposure  of  such  portion  of  the  tibia  as  is  de- 
sired for  the  removal  of  the  transplant,  and  so 
placed  that  its  closure  will  not  bring  the  skin 
sutures  over  the  bone  cavity  produced  by  the  re- 
moval of  the  graft.  The  skin  is  dissected  up 
from  the  periosteum,  which  is  left  undisturbed, 
and  the  muscles  attached  to  the  crest  of  the  tibia 
carefully  dissected  away.  The  pattern  of  the  re- 
quired graft  is  outlined  by  incising  the  periosteum 
with  the  author's  caliper  knives,  using  the  moulded 
piece  of  sheet  lead  or  a  probe  as  a  pattern.  The 
graft  is  taken  from  the  lower  internal  surface  of 
the  tibia  shaft;  this  part  is,  as  a  rule,  sufficiently 
broad,  and  furnishes  a  cortex-transplant  stronger 
and  denser  than  the  upper  portion  of  the  bone. 

If  the  graft  is  to  be  straight,  it  is  best  re- 
moved from  the  crest,  wide  enough  to  encroach 
upon  the  antero-internal   surface  of  the   tibia,   that 


262  MODERN    OPERATIVE    BONE    SURGERY. 

the  central  or  fulcrum  portion  of  the  curved  graft 
includes  the  crest  of  the  tibia,  and  each  end  is 
cut  obliquely  across  the  antero-internal  surface. 
The  advantage  of  the  graft  secured  in  this  way 
includes  at  its  fulcrum  portion,  the  dense  and 
thick  cortical  bone  of  the  crest.  This  is  quite 
essential,  because  the  strength  of  any  lever  is  de- 
pendent upon   the   strength  of   its   fulcrum  portion. 

It  has  been  found  that  kyphoses,  sharply  an- 
gular, and  of  short  duration,  especially  in  chil- 
dren, can  be  corrected  to  a  certain  degree.  This 
fact  should  be  taken  advantage  of  in  cutting  the 
graft  to   conform  to   such  amount  of  correction. 

After  preparing  the  gutter  or  bed,  the  spine  is 
brought  as  near  normal  condition  as  possible  by 
cautious  manual  pressure  on  either  side  over  the 
lateral  masses,  while  the  curve  of  the  spine  thus 
corrected  is  obtained  by  fitting  the  piece  of  sheet 
lead  or  probe  into  the  groove  of  the  split  spinous 
processes. 

The  technic  is  carried  out  as  above  described, 
with  the  addition,  however,  of  the  pressure  used 
in  relieving  the  deformity,  while  the  bone-pegs  or 
kangaroo  tendon  sutures  are  being  put  in  place 
to   hold   the   graft   in   position. 

The  straight  graft  is  procured  by  cutting  the 
tibial  cortex  through  near  to  the  medullary  cavity 
with  the  motor  saw,  following  the  periosteal  outlines 
already  made;  this  includes  the  saw  cut  just  to 
the  outer  side  of  the  tibial  crest  (Fig.  114),  and 
at  a  right  angle  to  the  one  already  made  on  the 
antero-internal    surface.      This    cut    must    be    made 


BONE-INLAY   GRAFTS   IN    POTT'S   DISEASE.         263 

the  whole  length  of  the  graft,  if  a  straight  one; 
if  a  moulded  one,  only  to  include  the  middle  or 
fulcral  portion.  At  either  end,  beyond  this  central 
or  crest  portion,  the  graft  outlines  the  marrow- 
cavity,  and  the  saw-cuts  therefore  need  only  come 
on   the   antero-internal   surface   of   the   tibia. 

At  both  ends  of  the  graft  a  saw-cut  is  made 
with  a  very  small  motor  saw,  or  a  number  of 
drill-holes  are  made,  and  finally  a  sharp  osteotome 
or   chisel   is   used  to  finish   freeing  the   graft   from 


Fig.  114. — Position  from  which  to  remove  the  graft  to  be 
used  in  a  case  of  Pott's  disease  where  there  is  marked  kyphosis, 
graft  being  bent  to  fit  the  curvature  by  saw  cuts,  i,  indicates 
the  outside  of  the  tibia;  2,  the  undisturbed  crest;  3,  the  loca- 
tion from  which  to  remove  graft.  This  location  gives  the  best 
possible  cortical  transplant. 

the  tibia.  It  is  now  grasped  with  the  author's 
graft-retaining  forceps,  then  loosened  with  a  thin 
osteotome,  which  is  forced  into  the  longitudinal 
saw-cuts,  and  pried  free  and  placed  in  the  pre- 
viously prepared  bed.  "In  order  to  be  entirely 
and  continuously  successful,  the  motor  saw  is  in- 
dispensable in  removing  the  graft;  especially  is 
this    true    in    adult    cases,"    "as    the    bone    is    very 


264  MODERN    OPERATIVE   BONE    SURGERY. 

dense  and  brittle,''  and,  even  with  the  greatest  of 
care,  the  bone  is  at  times  cracked,  or  the  graft 
broken  and  rendered  unfit  for  use.  The  chisel 
method  is  not  only  slow  and  bunglesome,  "but  the 
constant  blow  of  the  mallet  on  the  chisel  trau- 
matizes the  graft,  and  does  not  permit  of  its  ac- 
curate moulding."  Pain  in  the  part  operated  has 
also  been  observed  to  be  much  less  since  the  motor 
instruments   have  been   perfected  for   this   use. 

Fixation  of  the  Graft  in  Position.  If  the 
graft  is  a  straight  one,  it  is  held  in  place  by 
bone-pegs  passing  through  the  graft  and  the  split 
spinous  processes,  or  by  kangaroo  tendon,  by  first 
passing  a  strong  suture  through  one-half  of  the 
split  supraspinous  ligament  at  one  side  of  the  gut- 
ter ;  then  the  suture  is  passed  up  over  the  graft  at 
the  middle  portion,  and  through  the  other  split 
half  of  the  supraspinous  ligament  opposite.  This 
suture  is  drawn  taut  and  tied,  thus  approximating 
the  two  halves  of  the  split  supraspinous  ligament 
over  the  graft  at  its  central  portion.  The  ends 
are  next  secured  in  the  same  manner,  always  en- 
deavoring to  pass  the  suture  as  deeply  as  pos- 
sible, so  as  to  get  a  firm  hold  upon  the  ligament 
and  close  to  the  spinous  processes,  either  above 
or  just  below  them.  This  gives  firm  contact  of 
the  graft  to  the  separated  halves  of  the  split 
spinous  processes.  In  the  Albee  method  only  kan- 
garoo  tendon   is   used. 

In  certain  cases  it  is  advisable  to  place  the 
suture  either  in  the  supraspinous  ligament,  half 
way  between  the   spinous  processes,   or  at  a  vary- 


BOXE-INLAY   GRAFTS    IN    POTT'S    DISEASE.         265 


ing  distance  to  the  sides  of  these  processes,  m 
order  that  the  ligament  may  yield,  and  the  trans- 
plant be  completely  covered.  In  the  lumbar 
region,   especially  in  adults,  the   supraspinous  liga- 


Fig.  115.— Modified  Albee's  method  of  placing  bone-graft  in 
spine  for  the  cure  of  Pott's  disease,  c,  indicates  bone-pegs  used 
in  holding  inlay  in  position.  Arrozvs  on  body  of  vertebrae  show 
direction  of  force  of  weight  and  muscular  spasm,  which  causes 
crushing  of  diseased  bodies  of  the  vertebrae,  i,  indicates  the 
first  vertebrae  involved;  x  vertebrae  secondarily  involved;  B,  the 
healthy  vertebra  above  and  below  diseased  ones. 

ment  may  be  so  dense  and  tense  that  it  is  diffi- 
cult on  account  of  the  required  thickness  of  the 
graft  to  cover  it  as  it  should  be,  unless  the  verte- 


266  MODERN    OPERATIVE   BONE    SURGERY. 

bral  aponeurosis  is  incised  on  either  side,  just  ex- 
ternal to  the  line  of  sutures.  This  permits  a  sep- 
aration of  the  ligament  sufficient  to  cover  the 
graft. 

Before  the  two  ends  of  the  transplant  are 
securely  fastened  in  position,  it  should  be  made 
certain  that  the  inlay  graft  reaches  far  enough  be- 
yond the  diseased  vertebra,  both  above  and  below, 
to  include  at  least  one  or  two  spines  of  healthy 
vertebra.  It  should  be  emphasized  to  have  the 
graft  reach  low  enough,  because  of  the  natural 
obliquity  of  the  spinous  processes  in  certain  seg- 
ments of  the  vertebral  column,  as  in  the  thoracic 
region;  the  tips  of  the  diseased  vertebra  are  well 
below  their  corresponding"  bodies,  so  they  may 
somewhat  mislead,  and  the  applied  graft  may  be 
moulded  too  short,  and  not  include  the  healthy 
vertebral  spines  below  and  above.  The  sharp  pos- 
terior corners  are  removed  by  the  Rongeur  for- 
ceps, and  these  bone  chips  are  placed  about  and 
under  the  graft  ends  before  tying  the  graft  end 
sutures,  or  making  holes  through  the  spines  and 
the  inlay,  with  the  Yg"  motor  drill,  in  which  the 
bone-pegs  are  placed.  The  graft  ends  should  be 
sure  to  contact  with  the  spinous  processes.  The 
small  fragments  of  bone  so  placed  furnish  added 
foci  for  bone-proliferation,  so  it  is  more  certain  to 
amalgamate  the  graft  ends  to  the  contacting  proc- 
esses ;  this  being  borne  in  mind,  Macewen  pointed 
out  that  the  bone-graft  varies  in  its  osteogenesis 
in  inverse  ratio  to  its  volume.  In  other  words, 
the    smaller    the    graft,    the    greater    its    compara- 


BONE-INLAY   GRAFTS   IN    POTT'S   DISEASE.         267 

tive  surface,  and  the  more  active  its  bone- 
growing  ability.  It  has  been  further  demonstrated 
that  small  grafts,  because  of  their  size,  obtain 
their  nourishment  more  readily  from  their  sur- 
rounding serum  and  blood,  and  a  periosteal  cover- 
ing is  essential  for  continued  success.  The  author 
has  occasionally  found  that  kangaroo  tendon  breaks, 
and  he  has  added  to  the  fixation  of  the  graft 
bone-pegs,  placing  one  through  each  spinous  process, 
above  and  below  the  diseased  vertebra.  Kangaroo 
sutures  are  introduced  at  intervals  of  1/4//,  and 
are  now  passed  in  similar  manner  as  the  sutures 
mentioned  above,  until  the  entire  length  of  the 
graft  is  closed  in,  and,  with  the  addition  of  the 
bone-pegs,  firmly  secures  the  graft  in  position.  In 
making  the  transverse  saw  cuts  to  allow  the  graft  to 
bend,  it  is  accomplished  in  the  same  manner  as  a  car- 
penter cuts  a  board  to  cause  it  to  bend  about  a 
curved  surface.  The  graft  is  held  securely  by  the 
operator  with  two  of  the  author's  graft  retaining 
forceps,  one  at  either  end,  the  motor  being  held 
firmly  against  the  instrument  table,  and  the  saw 
overhanging  the  edge.  The  uniform  depth  of  the 
saw-cuts  is  regulated  by  placing  the  right  guard 
on  the  saw,  in  accordance  with  the  thickness  of 
each  graft.  This  simplifies  matters,  as  the  surgeon 
has  no  fear  of  entirely  severing  the  graft,  and  the 
saw  cuts  to  the  same  depth  at  each  point.  With 
the  Geiger  saw,  it  is  not  necessary  to  use  saline 
solution  to  prevent  burning  the  bone,  as  the  speed 
of  the  saw  is  very  slow;  this  is  an  important 
point,  as  water  or  solution  of  any  kind  is  espe- 
cially objectionable   in  bone   surgery. 


268  MODERN    OPERATIVE   BONE    SURGERY. 

In  the  application  of  the  curved  graft,  the 
surface  (bearing  the  transverse  saw-cuts)  nat- 
urally lies  next  to  the  gutter-bed,  with  the  perios- 
teal surface  posteriorly.  The  edges  of  this  graft 
contact  with  the  cut  surface  of  the  gutter.  The 
same  method  is  adopted  in  the  application  of  the 
sutures  as  is  used  in  securing*  the  other  shaped 
grafts,  with  the  exception  that  the  bent-in  graft 
is  completely  sutured  into  position  at  one  end, 
while  the  other  end  projects  ready  to  be  bent  in, 
and  the  interrupted  sutures  are  then  inserted  con- 
secutively until  the  projecting  end  of  the  graft  is 
reached,  and  the  placing  of  the  imbedding  suture 
is   complete. 

If  the  bent-in  graft  is  held  by  one  imbedding 
peg  or  suture  applied  at  each  end,  holding  it  bent 
into  position  while  the  other  pegs  or  sutures  are 
added,  the  graft  is  in  danger  of  fracturing  through 
one  of  its  transverse  saw-cuts.  In  any  case, 
whether  this  fracture  of  the  graft  occurs  or  not, 
it  is  well  to  reinforce  this  graft  by  placing  along 
each  of  its  sides,  at  the  maximum  point  of  curva- 
ture, thin  strips  of  cortical  bone,  cut  with  the 
motor  saw,  from  the  tibia  where  the  graft  is 
obtained. 

The  skin  is  closed  in  the  usual  way,  and  plain 
sterile  dressings  are  applied.  Thick  pads  of  gauze 
and  cotton,  varying  in  thickness  according  to  the 
degree  of  the  kyphosis,  are  placed  to  prevent 
pressure-necrosis  on  the  apex  of  the  grafted  ky- 
phosis. The  dressings  and  pads  are  then  securely 
fastened  in  place  by  strips  of  zinc  oxide  adhesive 
plaster,    i1/^'  to  2"  wide. 


BONE-INLAY   GRAFTS   IN   POTT'S   DISEASE.         269 

The  postoperative  care  of  these  cases  consists 
in  recumbent  posture  on  the  back  on  a  fracture- 
bed  for  five  weeks  in  adult  cases,  and  six  weeks 
for  children,  with  no  more  restraint  than  that 
afforded  by  pinning-  a  towel  about  the  chest,  to 
which  are  attached  four  strips  of  broad  muslin 
bandages.  Two  strips  are  pinned  to  the  upper 
side  of  the  encircling  towel  in  front,  to  be  secured 
to  each  side  of  the  mattress  of  the  bed  above  the 
shoulders.  The  remaining  two  strips  of  bandage 
are  fastened  to  the  encircling  towel  near  its  lower 
edge,  and  to  the  two  sides  of  the  mattress  at  the 
foot  end  of  the  bed.  These  restraining  bandage- 
strips  are  so  placed  to  prevent  the  patient  from 
attempting  to  sit  up  or  roll  from  side  to  side,  and 
are,  as  a  rule,  only  necessary  in  children;  adult 
patients    usually   lie    recumbent   without    restraint. 

Where  the  spine  presents  marked  kyphosis,  it 
is  necessary  to  apply  thick,  soft  pads  on  each  side 
of  the  spine,  before  placing  the  patient  on  his 
back,  or  when  there  is  an  excessive  deformity  it 
is  best  to  secure  the  patient  in  bed,  lying  upon 
his  side  to  obviate  undue  pressure  on  the  grafted 
area,  in  this  way  preventing  necrosis  of  the  skin- 
flap. 

The  slight  amount  of  motion  produced  by 
respiration  is  not  detrimental  to  the  adhesion  of 
the  graft,  but  rather  is  considered  a  stimulant  to 
callus  formation  between  the  contacting  cut  surfaces 
of  the  bone,  thus  hastening  the  fixation  or  graft- 
ing of  the  transplant  to  the  spinous  processes. 

It    should   be   observed   that   the    application   of 


2/0  MODERN    OPERATIVE   BONE    SURGERY. 

the  bone-graft,  for  the  purpose  of  ankylosing  the 
affected  vertebra,  accomplishes  the  long-sought-for 
immobilization  of  these  diseased  joints;  but  it  does 
not  directly  remove  the  disease  itself,  which  is 
an  impossibility.  However,  as  ankylosis  of  other 
tuberculous  joints  has  proven  so  satisfactory  in 
arresting  the  disease  without  requiring  the  re- 
moval of  all'  affected  bones,  so  in  case  of  tuber- 
culous infection  of  the  vertebral  joints,  ankylosis 
acts  with  even  greater  advantage  in  that  by  the 
bone-graft  implanted  in  the  spinous  processes  the 
vertebrae  are  not  only  ankylosed,  but  their  diseased 
bodies  can  be  separated,  thus  removing  active 
causation-elements  in  the  extension  of  the  disease. 
Although  as  a  rule,  the  patient  is  immediately  re- 
lieved from  symptoms  and  evidence  of  active  dis- 
ease, he  should  have  the  general  bodily  rest, 
nourishing  foods,  sunlight,  and  fresh  air,  which 
have  always  been  found  of  such  great  importance 
in   these   cases. 

It  is  advisable  in  these  cases  that  six  months 
or  more  of  postoperative  convalescence  shall  have 
passed  before  the  patient  resumes  active  or  heavy 
work.  Children  should  have  at  least  a  year  of 
restraint  from  general  activity,  with  daily  rest- 
periods,  and  out-of-door  life.  It  proves  very  bene- 
ficial in  these  cases,  following  the  five  to  six 
weeks  postoperative  confinement  in  bed,  if  they 
can  be  removed  from  the  city  to  the  mountains 
or  sea-shore,  where  the  surroundings  are  more 
healthy.  In  other  words,  they  should  be  managed 
in   a  similar   way  to   cases   suffering   from  lung  or 


BOXE-IXLAY    GRAFTS    IN    POTT'S    DISEASE.         271 

glandular  tuberculosis;  this  should  be  carried  out 
in   every   detail. 

As  a  rule,  Dr.  Albee  has  followed  the  prac- 
tice of  not  applying  external  fixation  to  the  spine 
after  his  operation.  There  are  exceptions,  how- 
ever, where  for  definite  reasons  it  has  been 
deemed  advisable  to  have  the  patient  wear  a  spinal 
brace  or  a  plaster-of -Paris  jacket  for  varying 
lengths  of  time  after  the  five  or  six  weeks  of  im- 
mediate postoperative  fixation  in  bed;  for  example, 
where  the  patient  is  obliged  to  leave  the  hospital 
before  the  prescribed  period  of  five  or  six  weeks 
in  bed  has  elapsed;  or  in  cases  where  a  marked 
kyphosis  in  the  dorsal  region  has  developed  before 
the  operation,  necessitating  a  temporary  weakening 
of  the  graft  by  transverse  saw-cuts  in  order  to 
bend  it  into  place.  In  addition,  such  a  graft  is 
subjected  to  strain  varying  according  to  the  sever- 
ity of  the  kyphosis.  In  these  cases,  a  plaster-of- 
Paris  jacket  is  advisable  for  a  few  months,  or  a 
longer  period  of  the  recumbent  posture. 

The  natural  leverage  action  of  each  vertebra  is 
not  lost  by  the  application  of  the  bone-graft,  but 
is  changed  from  a  crushing  together  of  the  bodies 
anteriorly  to  a  pulling  of  the  ankylosed  spinous 
processes  on  the  ankylosing  graft  posteriorly.  The 
change  from  the  crushing  effect  takes  place  in  the 
bodies  by  the  approximation  of  the  anterior  arms 
of  the  levers,  to  a  traction  effect  through  the 
long  axis  of  the  graft  implanted  in  the  ends  of 
the  posterior  arms  of  the  levers,  preventing  up- 
and-down   motion    of    the    spinous    processes.      The 


2/2  MODERN   OPERATIVE   BONE   SURGERY. 

fulcra  of  these  levers  remain  constant.  In  com- 
paratively early  cases,  where  sharply  angular  an- 
teroposterior deformity  of  the  spine  exists,  further 
progress  of  the  kyphosis  can  be  prevented,  and 
some  correction  maintained,  by  bone-transplanta- 
tion. Besides  accomplishing  this,  the  immobiliza- 
tion of  the  involved  segments  of  the  spinal  column 
is  secured  without  marked  interference  with  body 
activity,  or  respiratory  function,  and  does  away 
with  the  long"  protracted  palliative  treatment  ordi- 
narily resorted  to. 

Fixation  is  indicated  in  all  cases  and  at  all 
ages  where  pain  or  muscle-spasm  demands  it,  and 
the  earlier  the  operation  the  more  favorable  the 
prognosis;  it  is  essential  for  the  prevention  as  well 
as  for  the  correction  of  deformity,  and  is  even 
more  urgently  demanded  in  the  presence  of  com- 
plications, such  as  psoas-spasm,  tubercular  cyst,  or 
paraplegia. 

The  only  two  contraindications  are,  the  inabil- 
ity to  secure  a  clean  field  for  operation,  and  the 
debilitated  condition  of  the  patient.  The  first, 
however,  is  rare,  as  a  tubercular  cyst  seldom 
points  to  or  invades  the  region  of  the  spinous 
processes.  Uninfected  tubercular  cysts  between  the 
spinous  processes  have  not  interfered  with  the  pri- 
mary union  of  the  graft  when  encountered  unex- 
pectedly in  implanting  the  graft,  and  cases  can 
be  cited  where  bone-grafts  have  spanned  through 
these  tubercular  cysts  with  no  detriment  to  the 
graft  or  delay  in  its  bony  union. 

The    second    condition    does    occur    occasionally, 


BONE-INLAY    GRAFTS    IN    POTT'S    DISEASE.         273 

and   when   it   does,   the   patient's   system   should   be 
built   up   before   operating-. 

Prognosis  in  all  operative  cases  is  favorable  as 
to  relief  of  all  symptoms,  and  some  decrease  in 
the  deformity.  Correction  of  the  deformity  is 
largely  overcome  in  children,  if  operated  upon 
early;  and  in  cases  of  longer  duration,  where  the 
kyphosis  is  sharply  angular,  or  presents  a  consid- 
erable amount  of  motion,  a  certain  amount  of  cor- 
rection can  be  obtained.  The  prognosis  is  gov- 
erned by  the  patient's  postoperative  environments 
and  daily  conduct,  and  is  all-important.  Rest, 
forced  feeding,  fresh  air,  and  exposure  to  sun- 
light, are  the  essential  elements  of  the  after- 
treatment. 


is 


CHAPTER   XXXIX. 

Hibbs'   Operation   for  the   Cure  of 
Pott's   Disease. 

"Hibbs''  operation  (Fig.  116)  consists  in 
bringing  about  a  fusion  of  the  posterior  portions 
of  the  vertebra,   thus   preventing   pressure  on,   and 


Fig.  116. — Hibbs'  operation  for  the  cure  of  Pott's  disease. 
AA,  two  bodies  of  the  vertebras  diseased;  A,  two  healthy  ver- 
tebrae above  and  below  the  diseased  vertebrae ;  5,  A^ertebraa  not 
operated  upon. 

motion  of,   the  vertebra   that  is  undergoing  tuber- 
cular  disintegration. 

After  placing  the  patient  in  a  ventral  position, 
a  longitudinal  incision  is  made  over  the  diseased 
vertebra,  exposing  the  spinous  processes  and  the 
lamina.  The  spinous  processes  are  broken  at  their 
base  with  a  chisel,  and  so  placed  that  the  tip  of 
each  one  is  in  apposition  or  lying  on  the  broken 
base  of  the  process  immediately  below  it.  As  in 
all  other  operations  for  tuberculosis  of  the  spine, 
(274) 


HIBBS'    OPERATION    IN    POTT'S    DISEASE.  275 

one  or  more  spines  of  the  healthy  vertebra  above 
and  below  the  diseased  vertebra  must  be  included 
in  the  fixation.  The  periosteum  is  pushed  back 
from  the  adjacent  edges  of  the  lamina  to  their 
ventral  side,  after  its  removal  from  their  poste- 
rior surface.  A  small  spicula  of  bone  chiseled 
from  the  lamina  is  placed  transversely  across  the 
space  between  them,  its  free  end  lying  in  contact 
with    the   lamina   next   below. 

In  closing  the  wound,  we  bring  the  periosteum 
superspinous  and  interspinous  ligaments  over  the 
fragments  by  interrupted  kangaroo  tendon  or 
iodized  gut  sutures.  The  skin  is  closed  with  plain 
gut,  subcuticular,  over  which  a  sterile  dressing  is 
applied,  which  is  held  in  position  with  i"  straps 
of   adhesive,    an   inch   apart. 

The  postoperative  treatment  consists  of  abso- 
lute rest  in  bed  for  eight  weeks,  after  which  time 
the  patient  may  be  propped  up  in  bed  with  back-rest 
for  four  weeks.  A  well-fitting  brace  or  plaster-of- 
Paris  cast  is  applied  at  the  end  of  twelve  weeks. 
After  this  the  patient  is  gradually  permitted  to 
resume  the  erect  posture,  and  then  is  allowed  to 
take  moderate  exercise.  ,  At  the  end  of  sixteen 
weeks  the  brace  or  cast  is  gradually  removed. 
This  operation  induces  the  permanent  callus,  bind- 
ing together  the  fragments  and  the  posterior  parts 
of  the  vertebra  dealt  with.  It  prevents  motion  in 
the  vertebral  articulations,  immobilizing  indirectly, 
the  diseased  vertebral  bodies,  thereby  relieving  the 
symptoms  and  arresting  the  onslaught  of  the 
disease. 


276  MODERN    OPERATIVE   BONE    SURGERY. 

By  this  ingenious  operation,  Dr.  Hibbs  has  re- 
ported a  great  number  of  cases  of  Pott's  disease 
successfully  operated  on  in  the  New  York  Ortho- 
pedic Hospital. 


INDEX 


Abbott,  207 
Abscess,  270 
Absence  of  bone,  30 
Absorption  of  bone,  25,  26,  27,  51, 
54 
of  callus,  217 
of  transplant,  125,  217 
Adult  bone,  17,  263 
Albee,  31,  217 

Albee's  operation  in  Pott's  disease, 
256,  258,  259 
bone-inlay  graft  in,  259,  260,  261, 

262,  263,  271 
bone-pegs  in,  262,  265,  267 
contraindications  for,  272 
Geiger's    motor    instruments    in, 
261,  262,  263,  264,  266,  267,  268 
hemorrhage  in,  258,  259,  260 
incision  in,  258 
indications  for,  272 
modified  method  of,  265 
post-operative  care  in,  269,  270, 

271,  273 
prognosis,  270,  271,  272,  273 
restraining    bandage    strips     in, 
269 
American    Rontgen    Ray    Society, 

138 
Anatomical  relation  of  patella,  196, 

197 
Anatomy  of  periosteum,  20 
Angular  curvature  of  spine,  248 
Ankylosis    of    tuberculous    joints, 

270 
Antiseptics   in   bone   surgery,    104, 

105,  108 
Aplasia,    bone   transplantation    in, 
30 


Apparatus,  Geiger  orthopedic,  94 

Arm,  Geiger's  right-angle,  90 

Artery,  nutrient,  10,  15,  20 

Arteries,  12,  16 

Arthroplasty,  30 

Asepsis  on  bone  surgery,  40,   105, 

133 
Autogenous  bone  graft,  see  Graft. 

transplant,  see  Transplant. 

periosteal  graft,  126 

Bacteria — resisting  properties  of 
autogenous  bone-transplant, 
31,  56,  63,  140,  142 

endosteum  and  periosteum,  140 
Bandage,  use  of  gauze,  122 

plaster-of-Paris,  101,  122 

restraining,  269 

retaining,  98,  101 

spica,  99,  187 
Blake,  57 

Blood  supply  of  bone,  20,  21 
Blood    in    fractures,    see   Hemor- 
rhage. 
Blood,  good,  244 
Blood-vessels  in  bones,  10,  15 

in  periosteum,  19,  20 
Bond,  35 
Bone,  1,  5,  6 

absorption  of,  25,  26,  27,  29 

blood-vessels  in,  9,  10,  11,  13,  14, 
15,  16,  20,  21 

cancellous,  8,  9 

cartilaginous,  2 

compact,  6,  7 

endochondral,  5 

histogenesis  of,  1,  4 

histology  of,  5,  22 

(277) 


278 


INDEX. 


Bone,  injuries  to,  32 
nerve  supply  to,  10,  15 
regeneration  of,  18,  22,  23,  24,  28, 

29.  34,  58 
repair  of,  see  Repair, 
transplantation    of,    see    Trans- 
plant. 
Bone-cells.  1.  4.  17.  33,  34,  35 
Bone-clamp,  Geiger's,  92,  93,  134 
Bone-elevating  forcep,  Geiger's,  91 
skid,  Geiger's,  91 
spoon,  Geiger's,  91 
Bone-graft,    autogenous,    57,    116, 
238,      see      also      Inlay-graft, 
Graft,  Transplant, 
as  general  surgical  agent,  31,  54, 

63 
germ-resisting   property   of,    31, 

56,  63,  140,  142 
in  skull  defects,  246,  247 
in  tuberculosis  of  joints,  31 
osteoblast  important  in,  8 
osteogenesis  of,  266 
tedious     method     of     removing, 
67,  68,  264 
Bone-graft-retaining    forceps, 

Geiger's,  91 
Bone-grafting,    essentials    to    pro- 
cess of,  229 
Bone-grafting,  Murphy's  rules  on, 

24,  27 
Bone-marrow,  10 

Bone-pegs,  47,   124,   125,   151,   177. 
262,  265,  267 
superior  to  kangaroo  tendon,  115 
technic  in  applying,  124 
Bone-repair,  see  Repair  of  bone. 
Bones,   causes    of   injuries   to.   32, 

178,  179 
Bone-surgery,  asepsis  in,  105,  133 
closing  of  wound  in,  107,  275 
incision  in,  133 
motor  power  in,  67,  132 
preparation  of  field  in,  104 
technic,  104 


British    Fracture    Committee,    re- 
port of,  180 
Medical  Association,   report  of, 
65 

Burr  or   reamer,   Geiger's,  79,  81, 
85,  89 

Bursa  of  patella,  197 

Caliper    knives,    Geiger's,    85,    86, 

113,  120,  137,  186 
Callus,  absorption  of,  33,  38,  39 

failure  to  ossify,  215 

formation  of,  25,  33,  34,  38,  51, 
156.  165 

intramedullary,   33 

myelogenous,  33 

periosteal,  33 
Cambium  layer,   18 
Canal,  Haversian,  7,  15,  23,  26 

Yolkmann's  7,  15,  20 
Capillaries,  laceration  of,  32 
Caries,  50,  54 

Cartilage,  amount  formed  in  frac- 
tures, 36 

avoidance  of,  152 

histogenesis  of,  1,  4 

regeneration  of,  18,  19,  34 
Carter,  245 

Cast,   see   Plaster-of-Paris. 
Cellular  elements,  20 
Chisel  method,  slowness  of,  264 
Chondroblasts,  3,  18 

-osseous  junction,  3 
Chuck,  Geiger's,  77,  79,  80,  81 
Circulation,  arterial,  12,  16 
Clamp,  Geiger's  fracture  or  bone, 

92,  93,  134 
Clavicle,  fracture  of,  143,  144,  145 
Clinical  Congress  of  Surgeons  of 

Xorth  America,  69 
Clinics,  Murphy's,  70 
Club-foot,  232  ' 

incisions  in,  233,  234 

operative  treatment,  232,  233 

prognosis,  235 


INDEX. 


279 


Colles'  fracture,  176,  177 

bone-peg  in,  177 
Comminuted    fracture,    see    Frac- 
tures. 
Compound  fracture,  see  Fractures. 

causes,  217,  220 

classification  of,  131 

contraindications  for,  60 
Corpuscles,  pacinian,  15 
Cortical  bone,    124,    125,    128,  262, 

268 
Crile  theory,  132,  133 
Curved  graft,  261,  262,  268 
Cutters,  Geiger's,  80,  81,  89 
Cyst  as  indication  for"  bone-graft, 
30,  250,  251,  272 

Deformity,  bone-transplantation 

in,  30,  262,  272,  273 
Delayed  union,  215 

causes  of,  220 
Dense  bone,  6 

Diagnosis  of  fractures,  see  X-ray. 
Don's    method    in    Pott's    disease, 

256,  257,  258 
Dowels,   intramedullary,    120,    144, 
160,  166 
size  of,  120,  266,  267 
square,  150,  158,  179 
technic  in  applying,  120 
Dowel-shaper,  Geiger's  74,  86,  87, 

88 
Drill,  Geiger's  motor,  80,  124,  135, 

152,  166,  171,  187,  266 
Duhamel,  17 

cambium  layer  of,  18 
on  repair  of  bone,  18 

Electricity  in  surgery,  71 
Electro-operative     motor     instru- 
ments, see  Geiger. 
Electric  hot-air  sterilizer,  76,  81 
Elevator,  Geiger's  periosteal,  113 
Endochondral  bone,  5 
Endosteum,  7,  21,  35,  109 


Epiphysis,  absence  of,  29,  30 

separation  of  femur,  194 
Exostoses,  traumatic,  25 
Extension     device,     Geiger's,     see 
Geiger. 
table,  Geiger-Murphy,  see 
Geiger-Murphy. 

Face,  fractures  of,  141,  142 
Femoral  shaft,   fractures  of,   178, 
193 

autogenous    bone-graft    in,    179, 
182,  186,  193,  195 

cause  of,  178,  179 

Geiger's     extension     device     in 
treating,  98 

healing  of,  188,  189 

incision  in,  184 

metal  spike  in,  181,  182 

of  condyles,  194 

prognosis,  180 

spica  bandage  in,  187 

treatment  in,  180,  193 
Fibers,  Sharpey's,  7 
Fibroblasts,  34 
Fibrous  tissue,  7 
Fibula  as  transplant,  110,  112 

fracture  of,  204,  206,  216 

surgical  fracture  of,  204 
Fixation,  external,  57 

internal,  57 
Forceps,     Geiger's    bone-graft-re- 
taining, see  Geiger. 

elevating,  see  Geiger. 
Forearm,  fractures  of,  168,  177 

bone-peg  in,  170,  172,  174,  177 

Colles'  fracture  of,  176,  177 

external  treatment  of,  169,  177 

inlay  graft  in,  170,  175 

intramedullary     dowel     in,     170, 
172,  175,  176 

operative  treatment  in,  169,  171, 
175 

outside  dressing  of,  171,  172,  176 
Fracture-clamp,  Geiger's,  92,  93 


280 


INDEX. 


Fracture-clamp,  extension  appara- 
tus, 94,  98 

table,  102,  103.  184 
Fracture  of  clavicle,  143 

condyles,  166,  167,  194,  195 

coronoid  process,  171 

face,  141,  142 

femoral  shaft,  40,  46,    189,   191, 
193 

femur,  178,  180,  see  Femur. 

fibula,  204,  206,  216 

forearm,  168,  see  Forearm. 

hip,  178 

humerus,  146,  see  Humerus. 

inferior  maxillary,  141 

of  alveolar  process,  141 

olecranon    process,   46,   47,    168, 
169 

patella,  196,  202 

radius,  174,  176,  see  Radius. 

spine,  211,  see  Spine. 

tibia,  203,  see  Tibia. 

ulna,  173,  174 
Fractures,  bandaging  in,  see  Band- 
age. 

bone-peg  in,  see  Bone-peg. 

Colles',  172 

comminuted,  113,  189 

compound,  38 

cortical  bone  in,  see  Transplant. 

delay  in  treating,  129 

delayed  union  in,  215,  see  Union. 

diagnosis  in,  see  X-ray. 

dressing   of,    155,    164,   171,   176, 

187,  204,  206,  231,  268 
essentials  for  treatment  of,  126 
extension  device  in,  see  Geiger. 
formation  of  callus  in,  see  Cal- 
lus. 

fixation  in,  271 

fresh,  127 

Geiger's     instruments      in,      see 

Geiger. 
healing  of,  33,  156,  164,  171,  172, 

188,  189,  202,  204,  206,  212,  231 


Fractures,   hemorrhage  in,  32,  33, 

64,  106,  107,  112,  190 
incisions  in,  see  Incision, 
indication  for  operation  in,  130 
infection  in.  38,  40,  48,  50,  51,  62, 

139,  140,  220 
inlay  graft  in,  see  Inlay  graft; 

Graft,  Transplant. 
intramedullary     dowel     in,     see 

Dowel, 
intramedullary  transplant  in,  230 
immobilization  of,  231 
necessities  for  union  in,  215 
oblique,  203 
of  patella,  196 
operative  treatment  of,  46 
post-operative,  213,  222,  226,  228 
surgical,  204 

surgical  treatment  of,  220 
indications  for,  58,  63 
reduction  of,  40,  45 
results,  65 

simple.  32.  127,  131,  132,  135 
special,  141 
spiral,  203 
supracondyloid,  193 
time  to  operate  in,  129,  131 
transplant  in,   see  Transplant, 
treatment  of,  see  Treatment, 
ununited,  127,  133,  136,  215,  217, 

218,  219,  222,  231 
usual  location  of,  222 
use     of     foreign     materials     in 

treating,  51 
Functions  of  periosteum,  23,  24 
transplant,  27 

Gangrene,  190 

Geiger  armamentarium,  80,  81 
bone    instruments,    67,    93,    111, 
132.  133,  134,  186,  208,  266,  267, 
etc. 
burrs,  74,  79,  85,  88,  89,  90,  133 
caliper  knives,  85,  86 
chuck,  73,  79,  80 


INDEX. 


281 


Geiger  clamp,  92,  93,  134 
cutters,  70,  74,  77,  88,  89 
dowel  shaper,  74,  86,  87,  88 
drill,  74,  133,  see  Drill, 
electric  hot-air  sterilizer,  76 
elevating  forceps,  91 
foot  switch,  76,  77 
guide  handle,  83 
hand  switch,  76 
mandral  or  shank,  Si- 
method,   47,    108,    143,    158,    192, 

200,  265 
motor,  67,  72,  76 
osteotome,  263 
periosteotome,  86,  87 
reamer,  85 

retaining  forceps,  89,  91,  134 
right  angle  arm,  72,  90 
saw,  66,  67,  74,  80,  82,  84,  106, 

134,  267 
saw  guards,  84,  85 
slow  speed  motor,  see  Motor, 
spoons  for  skids,  92,  133 
sterilizable  shell,  74,  75,  77,  79 
switch,  72,  76,  77 
trephines,  74,  87,  89 
T-wrench,  73 
tube  saw  with  lathe  attachment, 

87,  88 
twin  or  parallel  saw,  74,  83,  90, 

134,  151 
Geiger-Murphy     orthopedic     and 

fracture  extension  table,   102, 

103,  184 
orthopedic   and   fracture   exten- 
sion apparatus,  94,  98,  100,  101 
saddle:  of,  96,  98,  99 
reduced  speed  motor,  68,  69 
Germs,  inherent  organization  of,  4 
Gloves,  use  of  rubber,  107 
Graft,   bone,    see   also   Transplant 

bone  graft, 
cortical  bone  in,  262,  268 
curved,  261,  268 
demands  upon,  170,  171 


Graft,  essential  to  success  of,  135, 
229 

fracture  of  curved,  268 

inlay,  48,  113,  116,  117,  118,  128, 
136,  137,  170,  etc. 

length  of,  266 

pattern  to  shape,  200,  261 

preservation  of,  106 

removal  of,  226,  261,  263 

single  saw  for  inlay,  137 

size  of,  136,  266,  267 

sliding,  114,  170 

straight,  262 

twin  saw  for  intramedullary,  137 
Graft-bed,  protection  of,  137 
Grooves,  24 
Gut,  chromicized,  56,  135 

Haas,  17,  24 

Haversian  canal,  7,  8,  23 
lamelte,  7,  8 
system,  7,  8 
Healing   of    fractures,    see   Frac- 
tures. 
Hemorrhage     in     fractures,     see 
Fractures, 
salt  solution  to  control,  107 
Hemotoma,  134 
Hibbs'  operation  in  Pott's  disease, 

256,  274,  276 
Hip-bone,  see  Femur. 
Hitzrot,  60,  63,. 66 
Humerus,  enlargement  of,  239 
avoidance  of  cartilage  in,  152 
epiphyseal  separation  in,  146 
external  condyle,  166 
fracture  of,  146,  167 
intramedullary  dowel  transplant 

in,  160,  166' 
internal  condyle,  166,  167 
Langenbeck's    incision    in,     148, 

156 
motor  instruments  in,  152 
non-operative  treatment  in,  146, 
159 


282 


INDEX. 


Humerus,  operative  treatment  in, 
146,  148,  150,  158,  159,  161,  162, 
166 
outside  dressing  in,  155,  156,  164, 

167 
prognosis  in,  146,  156,  164 
square  dowel,  150,  158 
T-fracture,  167 
Histology  of  chondrin,  1,  4 
cartilage,  1,  4 
bone,  1,  4,  5,  22 
periosteum,  5,  6,  15,  13 
Hump-back,  248 

Immobilization  in  fractures,  231 
Incision,    112,    120,    133,    144,    148, 
166,  184 

curved,  204 

Langenbeck's,  148,  156 

in  clubfoot,  233,  234 

semilunar,  258 

U-shaped,  199 
Infection   in   fractures,   see  Frac- 
tures. 
Injuries  to  bones,  32 
Inlay-graft,  36,  116,  128,  238,  256, 
see  Graft,  Transplant. 

limitations!  of,  117 

spool-shaped  type  of,  199,  200 

suitability  of,  116,  118 

tissues  comprising,  116 

use  of,  116 
Intercartilaginous  bone,  5 
Interstitial  lamellae,  8 
Intramedullary    dowel,     119,     120, 
160,  166,  see  also  Dowel. 

efficiency  of,  119,  128,  220 

indications  for  use  of,  119 

removal     of     periosteum     from, 
122,  150,  231 

graft,  238,  see  Transplant. 

transplant,  230,  see  Transplant. 
Intramembranous  bone,  5 

Jacket  plaster-of-Paris,  271 


Jaw,  fracture  of,  141 

use  of  rib  in,  142 
Jones,  129 

Jour,  of  Surgery,  Gynecology  and 
Obstetrics,  23 

Kangaroo  tendon  sutures,  use  of, 

110,  115,  163,  201,  264 
Knee-joint,  excision  of,  34 

infusion  into,  194 

synovial  membrane  of,  197 
Kyphosis  of  spine,  248,  249,  271,  273 

Lacunae,  of  bone,  7,  8 
Lamellae,  of  bone,  6,  7,  27 

concentric,  7,  8 

Haversian,  7,  8 

interstitial,  7,  8 
Laminectomy,  211 
Lane  plate,  51,  54,  62 
Lane's  bone  surgery,  40,  46,  62 
Langenbeck's    incision,     148,     156, 

238 
Lathe  attachment,  Geiger's,  88 
Leverage  of  vertebra,  271 
Limb,  position  of,  110,  121 

to  immobilize,  111 

Macewen,  18,  23,  266 

tissue  of,  17 
Mandril  for  saw,  Geiger's,  84 
Marrow,  bone,  10,  20 
Martin,  51 

Medullary  transplant,    see   Trans- 
plant. 
Mesenchyme,  4,  5 
Mesoderm,  4 
Metallic  plates,  46,  51,  63 

spike,  182 
Motor,    Geiger's    slow    speed,    74, 
see  Geiger. 

requirements  of  suitable  bone,  72 

weight  of,  72,  77 

bone    instruments,    Geiger's,    67 
see  Geiger. 


INDEX. 


283 


Motor,  instruments  and  shock,  132, 
264 
power  in  bone-work,  67,  71 
tools,  see  Geiger. 
Murphy.   John   B.,  23,  24,  28,   35, 

69,  70,  71,  180,  214,  244 
Murphy's  rules,  24,  27 
Musculotendinous  attachment,  29 

Necrosis,    avoidance    of,    54,    107, 
121,  140,  162,  220,  268,  269 

Neck  of  femur,  fracture  of,   180, 
181 

Neoplasm,  non-malignant,  30 

Nerves,  circumflex,  150 
musculospinal,  150 
ulnar,  166 

Nerve  supply  to  bones,  10,  15 

Neutral  position  in  fractures,  99 

New    York    Orthopedic    Hospital, 
276 

Non-operative  treatment,  see  Frac- 
ture, also  Treatment. 

Nose,  remodeling,  245,  246 

Nutrient  artery,  10,  20,  220 
foramen,  10 

Olecranon  process,  fracture  of,  46, 

47,  168 
Oilier,  18 
Open  treatment   of   fractures,   see 

Treatment. 
Operation,  "Albee's",  256,  258,  259 

"Don'',  257 
Operative  treatment  of   fractures, 

see  Treatment. 
Orthopedic  apparatus,  Geiger,  94 

advantages  of,  60 

caution  against,  62 

indications  for,  59 

technic  in,  104 
Os  calcis,  fracture  of,  207,  208,  209 

types  of,  207. 
Osseous  tissue,  6,  36 
Ossification,  endochondral,  2 


Osteoblasts,  3,  5,  6,  8,  17,  18,  19, 

21,  23,  26,  27,  205 
Osteoclasts,  27,  38,  39 
Osteogenesis,  21,  54,  116 
in  bone  graft,  136,  266,  267 
metallic  plate,  retards,  54,  63 
Osteogenetic    conductive    purpose, 
28 
function,  21 

power  of  periosteum,  24,  25,  26, 
27 
Osteitis  fibrosa  cystica,  transplant 

in,  240,  244 
Osteomyelitis,    54,    224,    225,    227, 

238 
Osteoplasts,  118,  238 
Osteosarcoma,  238,  244 
Osteotome,  263 

Pacinian  corpuscles,  15 
Palmer,  211 
Paraplegia,  272 

Patella,  anatomical  relation  of,  196, 
197 

fracture  of,  196,  198 

Geiger's  method  in,  200,  201 

operative  treatment  in,  199,  200, 
201 

prognosis  in,  99 
Perichondrium,  1,  2,  3 
Periosseous  layer,  6,  19 
Periosteal  elevator,  113 
Periosteotome,  87 
Periosteum,  5,  23 

anatomy  of,  20 

blood-vessels  in,  15,  19,  20 

cambium  layer  of,  18 

cellular  elements  in,  20 

closing  of,  121 

conclusions    of   authors   regard- 
ing, 21,  22 

examination  of,  15 

functions  of.  17.  23,  24,  35,  109, 
115 

histology  of,  5,  6,  15,  19 


284 


INDEX. 


Periosteum,  incision  in,  112 

Murphy's  rules  regarding,  24,  27 
must  be  removed,  109,  122,  186 
preservation  of,  110,  136 

Phemister,  experiments  of,  31 

Plaster-of-Paris  casts,  48,  62,  100, 
111,  117,  138,  171,  189,  214,  228, 
231,  275 
cutter,  111 

Plastic  zinc  oxide,  268 

Postoperative  fractures,  213 
treatment  of,  222,  226,  228 

Pott's   disease,  248,  see   Tubercu- 
losis of  Vertebrae, 
fracture,  49,  55,  206,  223 
Pott,  Percival,  248 

Pseudoarthrosis,  136 

Radiograph,   use   of,   50,   see  also 

X-ray. 
Radius,   fracture  of,  63,   172,  174, 
175,  176,  177 
structure  of,  176 
Reamer,  Geiger's,  85 
Reduced  speed  motor,  Geiger's,  68, 

69,  see  Geiger. 
Reduction  of  fractures,  see  Frac- 
tures. 
Regeneration   of   bone,   see   Bone, 
also  Repair  of  Bone, 
cartilage,  see  Cartilage, 
medulla,  34,  35 
Repair  of  bone,  32,  36 
absorption  of  callus  in,  33,  39 
autogenous   bone   transplant   in, 

see  Graft,  Transplant, 
clinical  aspect  of,  34 
electro-operative  instruments  in, 

see  Geiger. 
essential  features  in,  29 
fibrous  union,  in,  38 
foreign  material  in,  51,  63 
formation  of  callus  in,  33,  34,  38, 

156,  165 
formation  of  cartilage  in,  36,  38 


Repair  of  bone  in  early  childhood, 
33 
motor  power  in,  67 
non-operative  treatment  in,  62 
operative  treatment  in,   112,  see 

also  Treatment, 
osseous  tissue  in,  36 
ossification  in,  38 
osteoblasts  in,  36 
osteoclasts  in,  36,  38,  39 
periosteum    and    endosteum    in, 
35,  36 
Retropharyngeal    tubercular    cyst, 

250 
Rib,  use  of,  141 
Rongeur  forceps,  266 
Rontgen  ray,  see  X-ray. 
Rontgenogram,  138,  see  also  Skia- 
gram. 
Ropke  method,  246 

Salt  solution,  use  of,  107,  267 

Salts,  calcium,  33 

Saw,  Geiger's  motor,  see  Geiger. 

circular,  213 

guide  handle  for,  83 

parallel,  83,  113,  226 

shank  for,  84 

twin,  83 
Saw-guard,  85 

tube,  87 
Scarpe's  triangle,  250 
Sclerosis,  251 

Sclerosed  bone,  removal  of,  226 
Scoliosis,  45,  128 
Secondary  operations,  64 
Sharpey's  fibers,  7 
Shell,  Geiger's  sterilizable,  79 
Shock,  15,  132,  264 
Shortening  of  limb,  45 
Simple  fracture,  see  Fracture. 
Skiagraph,  9,  11,  12,  13,  14,  16,  28, 
37,  41,  42,  43,  44,  49,  50,  52,  53, 
55,  56,  61,  70,  147,  149,  153,  154, 
157,  160,  161,  162,  163,  164,  165, 


INDEX. 


285 


Skiagraph,  167,  168,  169,  172,  173, 

181,  183,  185,  191,  197,  198,  205, 

209,  215,  218,  219,  221,  223,  224, 

225,  227,  239,  240,  241,  242,  243 

Skids,  see  Spoons. 

Skull,  defects,  246 

bone-grafts  in,  246,  247 

cutter,  89 
Sliding-graft,  114,  151,  170 
Spica  bandage,  99 
Spicula,  bone,  5,  10 
Spina  bifida,  236 

osteoplastic  transplant  in,  236 

treatment,  236,  237 
Spinal  brace,  271 
Spine,    angular   curvature   of,   248 

ankylosis  of,  270 

caries  of,  248 

external  fixation  of,  271 

fracture  of,  211,  212 

kyphosis  of,  248,  249,  271,  273 

tuberculosis  of,  248,  274 
Spondylitis,  248 
Spoon,  Geiger's  bone-elevating,  92, 

133,  226 
Sterilizer,  Geiger's  electric,  76 
Stimson,  178 
Stitch,  subcuticular,  121,  135,  142, 

187 
Straight  graft  technic  for,  262 
Sutures,  110,  115,  163,  201,  264 
Switch,  Geiger's  foot,  76,  77 

hand,  76 

Technic  in  bona  surgery,  104,  105, 

119,  120,  122,  124 
Teeth,  wiring  of,  142 
Tendo  achillis,  tenotomize  the,  208 
T-fracture,  167,  194 
Tibia  for  transplant,  122,  136 

fracture  of,  203,  204,  206,  216 

diagnosis,  203,  206 

healing,  204,  206 

incision  in,  204 


Tibia,  intramedullary  transplant  in, 
203,  204 

oblique,  203 

postoperative,  213 

Spiral,  203 

with  fibula,  204 
Tissue,  cartilaginous,  34 

comprising  inlay  graft,  116 

fibrous,  7 

nerve,  15 

of  Macewen,  17 

osseous,  6,  34 

subperiosteal  areolar,  17 
Tourniquet   counterindicated,    106, 

233 
Transplant,   autogenous  bone,   see 
also  Graft,  21,  22,  26,  27,  28, 
29,  107,  211,  213,  266 

absorption  of,  123,  125 

changing  positions  of,  114 

cortical   bone   in,    124,    125,    128, 
262,  268 

essentials    for    success    of,    107, 
109,  115 

fitting  of,  162,  163,  170 

function  of,  27,  28,  203,  217 

ideal,  108 

indications  for,  30,  31 

inlay  graft,  36,  see  Inlay  graft. 

intramedullary  dowel,  120, 160, 166 
technic  in  applying,  120,  230 

length  of,  119,  135,  192,  266 

location  of,  116,  190 

peg,  124,  see  Bone-peg. 

protection  of,  137 

result  of  infection  on,  139,  140 

size  of,  109 

splitting  of  bone  in,  163 

technic  of,  58,  60,  135,  266 

vitality  of,  106,  115 

V-shaped,  145,  211,  234 
Transplant,  requirements  for  suc- 
cess of,  107,  109 
Transplanting   of   periosteum,    24, 
25,  26 


286 


INDEX. 


Traumatic  exostoses,  25 
Treatment  of  fractures,  126, 222,231 
autogenous   bone   transplant   in, 

see  Transplanting, 
closing  of  wound  in,  155 
delay  in,  129 
evolution  in,  40,  45 
external  or  closed  method,  65 
foreign  material  in,  51,  63 
Geiger  method,  188 
material  essential  in,  126 
motor  instruments  in,  see  Geiger 

old  method  in,  68,  152,  158,  192 
open  or  operative,  46,  65,  66,  118 
orthopedic   extension   device   in, 

see  Geiger. 
table  in,  see  Geiger. 
position  in,  99 

protection  of  graft-bed  in,  137 
Trephine  motor,  87,  89 
Tuberculosis  of  joints,  31 
of  vertebne,  248,  256,  274 

Albee's  operation  in,  256,  257, 
258 

bone-inlay  grafts  in,  256 

Don's  operation  in,  256 

Geiger's  modified  Albee  opera- 
tion in,  265,  267 

Hibbs'  operation  in,  274 
age  incidence,  249 
bone-inlay  graft  in,  256 
cervical,  253 
diagnosis,  252 
etiology,  248 


Tuberculosis,  pathology,  249 

prognosis,  253 

symptoms,  251 

synonyms,  248 

treatment,  254 
Tube  saw  motor,  87,  88 

lathe  attachment  for,  87,  S8 
Ulna,  fracture  of,  173,  174,  175 
Union,    bony,    causes    of    delayed, 
217,  220 

causes  of  rion-,  220 

things  necessary  to,  215,  217 
Ununited  fractures,  215 

Varieties  of  bone,  6 
Vertebra,  composition  of,  249 
tuberculosis   of,   see    Pott's    dis- 
ease. 

Volkmann's  canal,  7,  15,  20 

Whitman  position,  97,  98,  187 
Williams,  57 
Wire-sutures,  66 

use  of  copper,  or  silver,  54 
Wiring  of  teeth,  142 
Wolff's  law,  35,  118,  227 
Wound,  closing  of,  155 

X-ray  diagnosis,  50,  64,  126,  166, 
168,  175,  177,  194,  203,  207, 
253 

Young  bone,  17 
Y-shaped  fracture,  194 


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